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Posts Tagged ‘obsessive compulsive disorder’

Winston Churchill once described his depression as a big black dog that was his lifelong companion. Our poor kids also commonly suffer from any of a number of lifelong “companions,” one big one being obsessive compulsive disorder (OCD). Bigger than his big sensorimotor issues, speech dyspraxia, or medical issues, OCD is the number one challenge in Peter’s life. He describes it as “the terrorist,” the monster that “assails” his mind and behavior, that “vaccuums” his better thoughts and self. It is his “rate limiting step,” and has the greatest potential to limit his potential.

We have spent an enormous amount of energy working with Peter to help support him to get a leash on this problem. The results so far? See for yourself, and take a look at Peter’s essay below, in which he shares an inside look at how to battle the OCD monster. Though the battle is definitely a work in progress, it is his hope that in sharing his experience, he can share some practical and effective wisdom from his extraordinary team of consultants that will help other families in the same boat.

BATTLING THE OCD MONSTER

by Peter Tran

I was sitting in the car, grinning ear to ear after tons of work earning points by doing homework, exercising, and inhibiting my OCD. I finally earned the 50 points to go to Target!

​I absentmindedly started chewing on my pink goggles tapping toy strap. I guess it was a habit. You don’t think about what you are doing. The strap suddenly broke. I had chewed it clean through!

​By then we had arrived at Target. I felt overjoyed that we made it at last. I headed off to the stationery section for markers. The markers became excellent in my eyes because they were like a rainbow- red, orange, yellow, blue, purple, and green, long, good, smooth shapes, all neatly lined up in the box, full of possibilities. I could draw with them- imagine drawing Peter, good and successful. I could draw my favorite foods like meat, doughnuts, seaweed, and hotdogs, which make me happy. Mom doesn’t let me eat those often, so drawing them would be another way to enjoy them. I just drew myself eating a donut with rainbow sprinkles and a hotdog. I imagined it would taste heavenly, the hotdog hot and salty, and the donut soft and sweet. Drawing and imagining are great ways to enjoy something without doing it. Maybe I can do this with my compulsions.

​Anyway, I did get my box of markers. As I picked it off the shelf and held it in my hand, I felt very satisfied. Ahh! Just like scratching an itchy part. Unfortunately, my peaceful content did not last. I suddenly remembered I had ruined my pink goggles in the car. That made me feel like sharp, jagged red and orange lines!

​I pulled Mom up to the second floor. I knew just where the goggles were. I got a pink pair off the rack. I felt joyful that I could replace my treasure.

​But a nagging feeling lurked. Which prize would I buy? Fast disappearing was my victory. Instead I had a dilemma. What would I do? I wished I had not destroyed my goggles.

​At the check-out, I first put the goggles in the discard cart. The clerk checked me out. Unfortunately, I couldn’t move. How could I leave without the goggles? I needed those. I grabbed them back. The girl rang up a refund for the markers, and handed Mom the change. But then I couldn’t leave without the markers! Mom finally decided to buy both, and let me have one now, and earn the other. So she asked, “Which one do you want now, Peter?” I couldn’t decide. I grabbed the markers because they were my first love, and Mom whisked away the goggles in her purse.

​Unfortunately, all was not well. The markers didn’t fill my heart. I put some in my metal box where I keep my treasures and others in a plastic bag, but nothing felt right. Mom told me you cannot be satisfied with what can never satisfy. Truly, OCD can never be satisfied. It’s like a bottomless pit. Great was my disappointment. Instead of learning my lesson, my OCD found a new object. I ran around the house looking for the pink goggles. But Mom had hidden them well. They were not in her purse. I carried on for hours, insisting on going back to Target for another pair. But Mom said, “No, you must earn another 50 points.” I hounded her, but she held firm. Dad told her to take a break from me, so I lost her for the night, and with her, my best friend.

​I fussed all night, and continued badgering everyone the next day, but it didn’t help. What finally worked was writing this essay. I earned all my points, and got my pink goggles. Best of all, I got to be with Mom. And my OCD felt tamed. I didn’t feel as crazy.

​Unfortunately, that was just one battle. The “Target OCD” kept rearing its ugly head. I kept destroying goggles in less and less time, earned points frantically to go to Target to replace them, and then would start over again. Going to Target and buying goggles was not as satisfying as I hoped, and the satisfaction lasted for a shorter and shorter periods of time. By the time I was back in the car returning home, I was already asking for Target again. A friend of mine named Rosemary wrote a song for me to sing to talk back to my OCD:

“You’re a big fat liar, sowing doubt.

It matters not to me how loud you shout.

With Jesus in my heart I will not pout,

But chew you up and spit you out.

All you deserve is pure disdain.

All your tricks and ploys are plain.

God is my shepherd, He will reign,

His gifts to me won’t be in vain.”

I realized from my own hard experience that Rosemary’s song was true. OCD is a liar. The brain thinks it can feel good if you perform the compulsion like buying things at Target, but it doesn’t work.

​The sad thing is that reason is not enough to dispel OCD. I am still hounding my poor mother to go to Target. Despite knowing how meaningless it is to go to Target, despite loving my mother and knowing she is right, despite all the suffering OCD causes me and my family, I still am its captive.

I’m in chains, in mental agony.

Going round and round a merry-go-round

That revolves faster and faster.

I desperately want to get off.

My mind revolts against itself.

But all is a frantic gallop

To nowhere.

I can only pray for Jesus to cast out this demon.

I’m Not the Only One

​Tito Mukhopadhyay is another young man with autism and severe OCD. In the following passage (2008, pp. 186-7), Tito describes his experience of an obsession.

​”When I came to Hollywood, I got some new obsessions. One was riding a metro bus to a certain destination, and then returning by the metro underground train to the Hollywood Highland station From there, I would walk back home. It became my daily ritual.

​How strong was this obsession? I felt like I was inside a plastic box, suffocated all day long, until I could take those metro bus rides. I could not imagine myself not riding the metro bus and train, even for a day… What if (I) did not? I am sorry to say, that I would have a temper tantrum, which was beyond my control…

​My extreme obsession with train rides was beyond my reason and control, although I understood that I was being irrational about it. It is the same process that goes on in the mind of perhaps a chain-smoker, who, although he knows and understands completely well that he is not supposed to smoke, is still compelled to.”

​I like Tito’s analogies about his experience of OCD (pp.48-49):

“Those extreme obsessions happened like a sudden summer storm, with its rushing energy flowing within my body and mind. They happened with no definite direction and with a high and powerful intensity, ready to take control of my reason and behavior.

They paralyzed all my

Other thoughts,

So definite were they.

They had them absorbed.

They left havoc

Along their way,

They engulfed the nights,

And the stretch of days.

I heard banging of doors

From my own twisted hands,

Shadows screaming with worry,

Fear or confused triumph,

They powered me up

With a prolonged pain,

With no eyes to see,

No ears to listen.

They left me no mind

To think or realize,

They did their dance

Of some dreamless delight.”

​I think our experiences are very similar. I agree with his feeling that OCD vacuums the mind of reason and other thoughts. OCD often begins suddenly like a torrential rain, carrying the self away like a flood. It makes me feel affirmed to read about someone else experiencing the same terrorist assault. I am not lacking in character or effort. Severe OCD is a powerful enemy.

The Biologic Basis of OCD

​So what does research tell us about the physiological cause of OCD? OCD is caused by a brain glitch. The orbital frontal cortex senses danger, like an overwhelming need to dump a glass of water because otherwise it could spill. The signal goes to the anterior cingulate gyrus which connects to the limbic system, including the amygdala, which generates a huge sense of anxiety unless I dump the glass. Then the signal goes to the striatum, which is the place intention gets funneled into action pathways. The caudate nucleus is overactive in OCD and overwhelms the globus pallidus, which inhibits signals. The uninhibited signal travels on to the thalamus which is the relay center of the brain, and connects to the brain stem and spinal cord.

​Normally, the striatum ends the signal once the person realizes the glass is in a stable position (or the person realizes he already checked the door or turned off the stove). However, for a person with OCD, the striatum fails to inhibit the signal, and the thalamus restimulates the orbitofrontal cortex, and the circuit continues.

Intervention

​Neurons that fire together, wire together. So the more a person practices completing an OCD, the stronger the circuit gets, and the more he feels compelled to dump water, check the door, or perform whatever other compulsion the faulty circuit drives him to do.

​Therefore, the best nonpharmacologic treatment for OCD is to stop doing the compulsion. It is incredibly hard to do, but like everything the more the person practices, the easier it gets. So how does one practice disassociating the trigger from the compulsion?

​Let’s start with an illustration. Right now all I want to obsess over is going to Target. I want to replace my goggle strap. If you gave me a strap, I should be relieved, but I have a feeling that I would not be relieved. Therefore I believe I’m dealing with an OCD. So I’ll try to delay going to Target by writing this essay. The more I redirect my attention and energy into something productive, the better off I’ll be. I am building more mental control as I hope the intensity of the OCD subsides with each sentence.

​Right now, I’m starting to repeat “Target, Target.” Instead if I say “points,” I can shift my attention subtly from the obsession to doing something more productive, to earning points toward going to Target.

​This feels really hard. Every lower brain instinct is screaming to tell me I have to go to Target. The orbital frontal lobe sees no goggles or not the right goggles. The false thought is that getting the exactly perfect set of new goggles will quench a deep itch in my brain. My amygdala is firing fear and danger like mad. I must go to Target or be tormented with this feeling of craving or thirst or itch. On a scale of psychological stress between 1 and 5, 1 being calm ad neutral (no unsatisfied desire) and 5 being a frenzy to have the desired object of the OCD, I’m at a 4. (If I were at a 5, I would be hitting or scratching to get my way). So what do I do?

THE USUAL TREATMENT

​What is the standard treatment for OCD? In otherwise neurotypical people, the treatment is fairly orderly. Taking a bottom up point of view, the patient needs to sleep enough so he has enough energy to fight OCD. He needs to exercise enough to work out unproductive energy. The fundamentals must be dealt with or no success is sustainable. I find vigorous exercise like biking helps decrease my OCD the most. Keeping busy helps a lot too. OCD moves in unless something else occupies the mind. It might move in anyway but a blank mind is an invitation.

Cognitive Behavioral Therapy (CBT)

The first step identifying the problem. Some people can recognize they are getting upset when their hearts beat fast, they are breathing faster, or if they get getting clammy hands. I’ve never had much body awareness. I rely on my mom or aide to remind me of when I look upset. Then I try to see the reason. For example, yesterday, I frantically wanted to cut a rectangular piece out of my brother’s box of asthma medicines. It had a bright green stripe on it that I had to get a piece of. My mom stopped me, and asked, “Peter, is this a legitimate desire? Does it make any sense?” Only then did I realize I was facing an OCD.

​Then the patient learns coping skills to deal with the anxiety accompanying the obsession. Deep breathing, progressive muscle relaxation, and meditation often reduce anxiety. Once my OCD was really intense because we had just moved into a new house (stress may worsen OCD). Mom turned on my favorite rumba song. As we danced the rumba, my OCD anxiety melted considerably.

​Next the patient learns self-CBT, cognitive behavioral therapy. He learns to identify the false thought, and replaces it with a memory of real experience or truth. Then he thinks of alternative behaviors besides doing the obsession, maps out. The probable consequences, and chooses the best distraction. Over time the obsessive impulses diminish. Once I had an OCD about buying orange gift cards and cutting them up. I thought I had to do it or die. I realized the truth was that I was not in any real danger, and cutting up the gift card was wasteful, like cutting up money, so I changed my compulsion. Instead of cutting up the money part, I just cut up the tag. That took the fun out of it. Soon it stopped. That OCD went away.

Exposure Response Prevention

The best way to get rid of a more stubborn OCD is to take the offensive and do ERP, exposure response prevention. That is when you purposefully expose yourself to an OCD trigger, but don’t do the compulsion. Repeatedly do this with stronger and stronger exposures till you lose the desire to do the compulsion. Once I used this method on a compulsion to dump glasses of water. I sat in front of a glass of water for longer and longer periods of time inhibiting the desire to dump the water till I no longer had the habit. Repeated practice disassociating the trigger of the glass of water from the ritual of dumping it made that OCD so weak that I extinguished it.

​I used to clean off my utensil and plate between servings, although I knew I would eat more. I felt I had to do so because my food would look and taste better in a clean dish. Putting a new serving of food in a used dish would make the new food accidentally dirty, but I realize that the new food doesn’t get harmed. Also cleaning off my dish and utensils between servings had a downside. My napkin got soiled. So I made myself eat a new serving off of my old dishes over several meals. It took effort at first not to wipe my plate and utensils constantly, but got easier pretty fast. It only took me a few days to conquer that one.

​Neurotypical people use this ERP method systematically. They make a list of OCDs from easiest to hardest to resist. They do ERP for the weaker OCDs and work their way up the list, celebrating each victory as their inhibition grows stronger and the OCD grip on their life grows weaker. Once they are done with the list, they remain vigilant for new OCDs, squashing them as soon as they pop up while they are still weak.

STEPPED UP TECHNIQUES FOR HARDER CASES

​Uneasy Truce

In people with autism you might not be able to extinguish OCD. For me, OCD feels like a direction my brain falls into naturally. So if I extinguish one OCD, another rises to take its place. If I tried to extinguish every compulsion I think my brain would keep looking for something to obsess about. So I divide my obsessions into “good” ones and “bad” ones. “Good” obsessions are ones I can use as “sled dogs,” meaning still live productively with. I explain more about that later. “Bad” obsessions are destructive and harmful. I live with my “good” OCDs and work on eliminating or at least decreasing the “bad” ones. The situation is like the good and bad bacteria in the gut. Good bacteria crowd out the bad. But it’s an uneasy truce. The “good” obsessions can transform into “bad” obsessions, like my increasing need to go to Target to replace goggles I would chew up. So I have to be vigilant. If an obsession turns “bad” or out of control, I can’t use it anymore to keep my brain from engaging in a worse one.

Taming the Tiger

If an obsession gets more intrusive, I need to fight it harder. Once I was sitting in speech therapy, when suddenly I had a sudden compulsion to grab a green pen I saw in Miss Shohig’s pen can. There was no reason or thought behind it. I just felt I had to have that pen. I imagined taking the pen apart. I had been into disassembling pens lately. Mom wouldn’t let me have the pen, and Miss Shohig put the whole can in another classroom. I tried to resist the compulsion and turned my attention to answering her speech questions. While my upper brain answered questions, my lower brain tormented me by insisting I get a green pen. Finally, I stood up abruptly and made a run for it. My mom ran after me. I saw a row of closed doors. Which one had she hidden the pens behind? I flung open a door and peered inside. The teacher looked up, startled. Mom closed the door and held me tight. She got me to the car. Miss. Shohig hid the can of pens for a number of sessions. My mom’s and Miss Shohig’s determination did extinguish that OCD. Now i can go to speech without craving a pen. The lower brain can be taught, but it may require force, liked Mom physically preventing me from my seeking the pens.

Using Creativity

Sometimes you can try to get ahead of a runaway OCD. One day, Mom and I were sitting at the cafe at the exit of the Huntington Library. I earnestly wanted to work on my obsessive goggle tapping. It was keeping me from sleeping. So we tried some ERP. Mom put my goggles on the table. I set the timer for 5 minutes. The goal was to see if I could not tap for 5 minutes. To handle the anxiety, I turned to writing poetry.

“Closing Time at the Huntington Library”

I hear the soft splash of a fountain.

I hear the quiet murmur of voices,

broken by a harmonious chorus of “oh’s!”

as the baby next table over

had a mishap.

North I see the soft warm lights of the gift shop

shining through the glass walls.

They feel welcoming and comforting.

To the South I see a fountain,

like a big bowl with water flowing over its lip.

I see a soft golden haze behind hoary green gray desert leaves,

fading in a line to the horizon.

To the West is a brilliant blaze of setting sun.

I turn my face toward the East

and head home.

I felt much better. I realized I could survive without tapping incessantly. I was able to sleep better and kept my goggles out of sight in a drawer. I hear ERP usually doesn’t work that fast. It usually takes many sessions of exposure without getting to do the compulsion.

​Instead of extinction of all OCD’s, instead of a cure, my goal is to develop more self control, meaning inhibition and attention-shifting. So short of extinguishing OCD’s, one can shorten the duration of engaging in the rituals. Delay doing the ritual. Engage the upper brain to creatively change up the ritual. At times I’ve used my creativity to avoid bad behavior that an OCD was making me do.

​One time I had a crazy compulsion to cut up bright colored paperback book covers. That included an orange music book of Raffi songs and my mother’s medical review books, each of which had a bright red stripe.

I want you, orange book,

of the bright, glossy, orange look.

The smiling man, Raffi’s the name,

music man, of children’s fame.

Oh orange book

of the glossy look,

how I long to cut up your pages

Snip, snip, rip your cover fair,

more fun to cut than juicy hair.

If I could put my hands on thee,

my compulsion would so satisfied be.

Oh orange book,

Oh orange book,

How I long to cut up your pages.

A juicy slice my fingers feel,

curling strips like an orange peel.

A crisp sound cuts nicely through the air,

as my scissors make a sharp, straight tear.

Oh orange book

of the glossy look

how I long to cut through your pages.

But at the end of my rampage,

Alas! delight is just a phase.

A ruined book, disfigured and sad

reveals the mind gone partly mad.

And so poor book, rather than such a story,

I’ll leave you to your pristine glory.

I’ll turn my mind to poetry and math,

eat my dinner, and take a bath.

Putting Away Visual Triggers and Compartmentalization

The poem shifted my attention for one night, but alas! my OCDs do not fade readily. I kept going after the books. Mom hid those books away, but I found others. The obsession came to a head right before Christmas. Mom and my brothers finally had to pack up all the books on Christmas Eve when I was asleep. Mom left one shelf of books she was going to throw away anyway, and told me to just cut up those books. That compartmentalization really helped me. I see good books she neglected to pack away sometimes, but I go for the ones in the discard shelf instead. Takes some effort to walk away from the good books, but it’s manageable.

Sled Dog Instead of Wild Dog

The strategy I use the most is delay. When my OCD acts like a wild dog and makes me talk about going to Target again, I figure that at least I can use its crazy motivational power to get something productive done. So I turn the compulsion into a reward. Mom tells me I can go to Target if I earn points. I might earn a point for each lap I swim or sentence I write or edit. That way I not only leash but harness the energy of the OCD, turning the wild dog into a sled dog.

Right now I am writing to earn 150 points to buy a new set of goggles. I did a terrible thing. I love to tap on swim goggles. Swim goggles have just the right amount of bounce in them, and they don’t make too much noise. I had chewed through the strap of my own goggles. I remembered Mom had a pair in her swim bag, so I stole them. Poor Mom. She really missed those goggles, as she had taken good care of them for years. When I stole them, my OCD told me they would satisfy the craving in my mind for goggles. But instead, OCD made me chew up the straps (on my Mom’s) till they disintegrated in just two days. So now both Mom and I have nothing. My craving is as intense and painful as ever. I am in no better shape than I was two days ago. Actually, I’m in worse shape because I have lost Mom’s trust as I stole from her bag, and we are both goggle-less.

​Yet though I know the OCD is a big, fat liar and causes suffering and destruction, I still feel compelled to go to Target and buy another pair of goggles. In other words, I feel compelled to repeat the same behavior. Buy goggles, destroy goggles. The only pleasure in the cycle is to bite into those straps. But do I even get pleasure out of that? Not really, I just feel driven. I’m not free to enjoy anything, just a miserable slave. I think I know exactly how a drug addict feels. He would lie, steal, and harm those he loves to do something that doesn’t even give much pleasure anymore, something he hates to do. OCD has no logic, reason, or mercy.

​Once I replaced my Target obsession with a true thought like, “I don’t really need to go to Target. I lived happily for most of my life, going to Target only infrequently. Going to Target only makes me happy very briefly anyway.” Then I brainstormed alternative solutions and mapped the probable consequences. I could decide to get Mom to take me to Target. I might buy another pair of goggles. But then I would be feeding an ugly OCD that gives me no joy anyway. By experience I know this. Alternatively, I could go to Rite-Aide and buy markers. Purple, brown, orange, yellow, I could enjoy the colors. I could walk to Rite-Aide which would burn off some calories. doing something different would stretch my OCD and not reinforce my monstrous Target OCD. I chose the better solution that time. I chose to go to walk to Rite-Aide to buy markers.

​I felt good about that decision. But what about this time? I really do need a pair of goggles to tap, and have lost my other pairs. I’m only a few points away from earning another trip to Target. Yet I know that going to Target completes a bad circuit and reinforces it. Maybe I can stretch myself, but not too much. Once I go to Target and buy the goggles, I will set myself a target date of making the goggles last at least two weeks before I let myself go to Target again.

I did actually make it for 10 days without destroying my goggle straps . That was a big improvement for me because at my peak of OCD intensity, I was destroying new straps before the day was done. I think the knowledge that I wasn’t going to Target for 14 days helped my lower brain to rein in. I had four more days to wait, but did survive.

 

Unfortunately, when I did make it to Target, I blew it. I bought a pair of goggles but destroyed them kind of immediately. I didn’t get much pleasure out of it either. At first I felt discouraged with my failure. Then I realized I can learn from my mistakes. I realized I need to set a firm limit on this Target OCD. I made it for ten days without destroying my goggles before. Next time I earn goggles, I will tell my lower brain that I can’t go to Target again for ten days at least.

Keys to Success

I realize OCD has a positive side. The Frostig Center published a study on kids with learning disabilities. The kids who grew up to be most successful had six characteristics. First, they had good self-awareness. In battling OCD, the first step is to realize you are having an OCD, and need to resist giving in. Second, successful kids knew how to set goals. You get lots of practice thinking up different things to do instead of the crazy compulsion. That’s setting a goal. Whenever I turn my “mad dog” OCD into a “sled dog” reward, I’m also setting a goal. Third, you have to be proactive and actually do what you planned to delay, change up, or not do a compulsion; proactivity is another characteristic.

Fourth, successful kids had good skills coping with emotions. When fighting OCD, you get plenty of practice with deep breathing and talking to yourself. Fifth, successful kids had perseverance. All those repetitive thoughts give lots of opportunity to become persevering fighting them. Finally successful kids were good at creating and using support networks. I could never survive OCD without teamwork. My mom and tutor, Belinda, help me all the time. It’s love that makes it possible to fight OCD. It’s hard enough to fight it with loving support; without it, the constant struggle would be impossible to keep up.

 

So despite the pain and suffering it causes, I guess OCD can actually be a training ground for success.

 

I thought you had no purpose,

I thought you were my bane,

But without you Target OCD,

What motivation would I rein?

 

Instead of being Wild Dog,

I made you, Sled Dog, run.

By earning points for sentences,

My essay now is done.

 

References

 

Mukhopadhyay, Tito. (2008) “How Can I Talk If my Lips Don’t Move?” New York: Arcade Pub.

Raskind, M.H., Goldberg, R.J., and Higgins, E.L. (November 2003) ‘Predictors of Successful Individuals with Learning Disabilities, A Qualitative Analysis of a Twenty Year 501

Longitudinal Study, ‘Learning Disabilities Research and Practice,’ Vol. 18, Issue 4, 11/03, pp. 222-236

dong-combat-your-monsters.jpg

dong-combat-your-monsters.jpg

 

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“No! No!” With a mad gleam in his eye, Thomas dashed forward for the glass. He snatched it out of his mother’s hand, and made it to the sink in three mighty strides, dumping the contents with a look of relief and triumph on his face. Then he quickly refilled the glass with juice and exactly five ice cubes.

 

Harry wailed as he screamed at the top of his lungs, “You just want to give me more work! This is using up my free time!” as Mom corrected his math homework.

 

Do you sometimes feel like you live in a nuthouse? That as soon as your child with autism and OCD (defined below under footnote [1]) gets over one compulsion, a new one (or two or three) springs up to take its place? That the “neurotypical” younger sibling with the low frustration threshhold explodes whenever you do homework together?

 

I put these cases together because they actually occurred in tandem one afternoon to a family I work closely with. It was a mess of a day, struggling with these disparate situations involving children having completely individual profiles and challenges, but afterwards upon reflection, Mom realized that she had used the same method called CBT, cognitive behavioral therapy, on both.

 

So what is CBT (see definition below under footnote [2] )? Is it something parents have to spend a lot of money to get from mental health professionals for their crazed children? Or can you try it yourself right at home in the trenches? The answer is definitely yes for latter, and possibly yes for the former. Parents can definitely learn to use CBT effectively on their own in the home. Professionals can add critical support in tougher cases, but the more a parent practices CBT on their own, the fewer consultations will be required, and the more fruitful those sessions will be.

 

The following steps were adapted from Dr. Anne Marie Albano’s excellent book, “You and Your Anxious Child,” (2013), Penguin Books. She’s the director of the Columbia University Clinic for Anxiety and Related Disorders.

 

Step One: Help your child learn the identify the negative feeling while it’s happening, with the goal of doing so early, before the emotion grows too intense to cope with.

 

Thomas’s case: Too late! Thomas went from 0 to 60 in seconds without warning- ice cubes triggered the OCD, and he was unbearably anxious immediately, acting on it (dumping the ice cubes) before there was any chance to engage those frontal lobes. But that’s ok. Mom was quite sure there would be a next time. So she talked about how wow! he must have felt pretty anxious when he saw there were too many ice cubes. She drew an emotional thermometer scaled 0 to 5, and he pointed to the 4.

Harry’s case: Also too late! At first Mom was puzzled- Harry got upset so suddenly, without warning, and in her opinion without any provocation- by fourth grade, surely he should expect having to correct his homework. But upon reflection, she realized that it was not her demeanor nor demand that had anything to do with the problem, but the situation combined with Harry’s temperament. He was proud of having done his homework on his own, and was looking forward to relaxing. He has a low frustration threshhold, so the thought of possibly having to start all over again when he was already tired was too much. Mom realized the importance of the two of them having a discussion about expectations (expecting his homework to be corrected), setting aside time for it, and limiting extracurriculars so that enough homework time could be set aside and scheduled early enough before he tired out. Especially for our kids with short fuses (so no warning time), setting up for success is critical. This kind of forethought and preparation may not only be your best but only option to avoid an explosion.

 

However in general, for the next time, how does one teach a child to recognize a negative emotion early, before it grows to overwhelming proportions? According to the book, during a calm time, you’re supposed to take the time to teach your child how to identify the physical feelings of anxiety, so he’ll be able to spot it in himself early. For example, you can draw a body map of your child on a big piece of butcher paper, and draw arrows to the chest labeling a tight, explosive feeling or racing heart, lungs for rapid breathing, wrist for rapid pulse, forehead for perspiration, hands for cold and clammy, abdomen for gurgling or tummy ache, etc.

 

For Harry, Mom also wrote on the pink side of an index card: “Homework Explosion Signs! Turning away. Raised voice volume and pitch. Fidgeting and throwing erasers. Blaming. Changing the subject.” Although I wouldn’t try this with every kid as it might make him madder, she also videotaped :Harry once during an explosion, so he could see what it looked like. Both of those “self-awareness” measures have reduced the explosions, even though Harry has never once viewed the videoclip, and Mom usually has only to mention and not even pull out the card.

 

Step Two: Address the Emotion

In a way, it was easier to address Thomas’s emotion because his anxiety resolved immediately upon performing his compulsion (easy only in the short run, BAD in the long run because the more times he performs a compulsion and feels relief, the stronger that connection between the compulsion=relief becomes in his mind, and the stronger the compulsion becomes).

 

But for Harry, dealing with the emotion was the hard part. All Mom could do is be silent and present until he stopped screaming and yelling, since he couldn’t hear her anyway even if she tried to talk. After a period of ranting about the “extra work,” he started ranting about why Mom was just sitting there instead of moving forward, “wasting more time.” Sigh! When she tried to quietly tell him he needed to calm down so he could hear her, and then she’d talk, he just yelled louder. When she suggested deep breaths and tried to demonstrate them, he just got madder. So finally she decided “being present” was actually providing an audience that wasn’t helping. Mom told Harry he could come get her when he was ready to work, and left. Lucky for her, Harry really did want to finish his homework, and did eventually calm down (barely) enough to finish going over the corrections. That was an accomplishment. In earlier days, she had had to send him to his room with a timer to make sure he didn’t just go and play and get out of his work. Several such time-outs were necessary for him to get the point that cooperation (fixing his homework mistakes) was required and inevitable.

 

If it were possible to catch these emotional “dysregulations” at an earlier, more manageable stage, perhaps they could have done deep breathing or PMR (progressive muscle relaxation) to put a halt to the growing anxiety. Deep breathing is “balloon breaths” where the child puts his hands on his abdomen and feels his fingers expand out (“blow up the balloon”) as he takes a deep breath on the count of 5, and slowly exhales (“blow out the birthday candles”) on a count of 5. You’re supposed to teach deep breathing exercises and “progressive muscle relaxation” (in which you teach your child to sequentially contract/tense up the various muscles groups and then relax them from head to toe) as exercises a couple times a day, as a fun family routine activity, so they’re automatic when you need to use them to cope with anxiety.

 

Often humor works the best. For Harry, if Mom thinks some homework item is going to be hard, she’ll say, “Now don’t panic, Harry, this’ll be okay!” before tackling the problem, and get a smile out of him. She used to say, “Oh dear- here comes the lion! I think he’s ready to roar!” when he was younger, and the imagery was fun and helpful. “I think I’ve got an angry cat!” still works to clear the air sometimes.

 

Step Three: Help the child identify the untrue, negative thought, in other words, the distorted thinking that does not match up with reality. Then come up with the true, positive replacement thought together. It is NOT advisable to try this until the child has calmed down!

In fact, usually this step can’t even happen at the first incident. You usually get through the incident as best you can- for example, Thomas had already performed his compulsion. Harry and I had already gone over his homework corrections. Once the child is relieved from the stress/demand, and has thoroughly calmed down, you can sit down and go over this step for the next time.

 

Thomas’s case:

Mom drew a sad face (actually two eyes with upgoing eyebrows and a horizontal zigzag for the mouth) with a blank balloon thought bubble that they filled in with Thomas’s answer.

Mom: “So Thomas, what were you thinking when you saw the ice cubes before you dumped them?” Thomas: “I need five ice cubes or I won’t be okay.”

Then she drew a happy face with a blank balloon speech bubble that they filled in with Thomas’s next answer.

Mom: “So what’s the actual truth? What can you tell yourself and say back to the OCD?”

Thomas: “I’ll be okay with any number of ice cubes.”

 

Harry’s case:

Mom: (First we worked on getting down the negative thought on the pink side of an index card.) “So Harry, is this what you were thinking?”→Then they worked together on the true, positive thought which they wrote down on the back (white) side of each card.

1) “Mom is making more work for me.”→

“She is checking my understanding or giving me more needed practice.”

2) “This is too difficult and takes way too long. I’ll lose all my free time.”→

“Breaking it down like this will help me get it faster and save time in the long run.

Mom will set the timer and make sure we only work this long, so I’ll have plenty of free time.”

 

(Here are some other common ones, but I wouldn’t recommend presenting them all at once:)

3) “Making mistakes means I’m bad or stupid.”→

“Making mistakes is a normal part of learning. The faster I recognize a mistake and learn how to fix it, the faster I’ll learn.”

4) “Mom is correcting me because she thinks I’m stupid or don’t get it.”→

“Mom is correcting me because she knows I can understand and do this even better.”

5) “Mom is trying to punish or delay me by giving me a time out.”→

“I can’t learn when I’m too upset. I’ll learn better and faster if I give myself a little time to calm down.”

 

Step Four: Brainstorm management (“dealing with it”) strategies.

Thomas’s case:

Mom: “So Thomas, next time you see a glass with something other than five ice cubes in it, how are you going to deal with the OCD?”

Thomas: “I can squish it by delaying it.”

Mom: “Great idea! Shall we set the timer for 5 minutes or 10 minutes?”

Thomas: “Five minutes.”

Mom: “While the timer is going, what can we do to help you with the anxiety? Balloon breaths?”

Thomas: :”Squeezes.” (He likes hand squeezes.)

Mom: “And what do you tell yourself?”

Thomas: “Any number of ice cubes is okay.”

Mom: “And remember the doctor told us we should also plan a way to get busy while the timer’s going. Should we do math facts? Lunch?”

Thomas: “Lunch.”

 

Harry’s case:

Mom: “So Harry, next time you start panicking about homework, how can I help you?”

Harry: “I don’t know.”

Mom: “Do you feel it coming on or do you just suddenly explode?”

Harry: “What do you mean, ‘explode’?”

Mom: (Starting to show him the pink side of the card from step one) “You know, the homework explosion.”

Harry: (laughing) “Oh. I don’t know. I just get mad.”

Mom: “Maybe it just broadsides you. How about if I see signs of it coming (you know, the clenched fists and high voice), we try the deep breaths?”

Harry: “No! I don’t like doing those!”

Mom: “How about push-ups or jumping jacks?”

Harry: “No! I won’t do them!”

Mom: “Well, ok, but if I hear you make those negative thinking statements, I’m going to hand you a pink card.”

Harry: “What do I do with it?”

Mom: “Turn it over and try on the other way of thinking.”

Harry: “Ok, I’ll try it.”

 

Step Five: Set up contingent, controlled rewards, meaning positive consequences the child chooses and can look forward to. The reward should be simple, controlled: meaning not generally accessible (if the child has ready access to it anyway, it won’t mean anything), dependent on replacing the maladaptive with the adaptive behavior, and given as immediately as possible after the positive behavior.

Thomas’s case:

Mom: “Thomas, I can see you working hard on this ice cube OCD. Ready to tackle it head-on?”

Thomas: “What do you mean?”

Mom: “The doctor says that you can stop OCD’s faster when you exercise your “stop muscle” in the brain.”

Thomas: “That’s her answer for everything. Practice.”

Mom: “True. So she suggests doing ‘exposure-response’ homework. Twice a day, we give you a glass of water or juice with some other number of ice cubes than five. You stop yourself from dumping the ice cubes for five minutes on the timer.”

Thomas: “Then what?”

Mom: “You do what you like with the drink. I’m hoping you just drink it, and find you don’t have to dump it after all. OCD is like a wave. If you wait it out, it passes over, and you won’t feel the need to dump anymore. We can gradually increase the timer to wait for longer lengths of time, till you get to that point.”

Thomas: “Ok.”

Mom: “Once you’re not dumping drinks anymore, we’ll celebrate, and go out and buy some of your favorites!”

 

Harry’s case:

Mom: “So Harry, next time we have a lot of homework to correct, how do you want to handle it?”

Harry: “Just let me do it, and don’t check it.”

Mom: “That sounds like a great goal. I’d love to do that once you’re ready.”
Harry: “What do you mean by ‘ready’?”

Mom: “When you’re checking your homework yourself, and correcting your own mistakes.”

Harry: “Mom! That’s too hard!”

Mom: “So we’ll get there step by step. The first step is checking the first three problems of your math homework yourself today. If you do, and they are correct when I look them over, you get three pennies in the homework jar. We can talk about what you want to use the pennies for- you can turn them in for a playdate or computer time.

In the meantime, what do you think a reasonable amount of time to spend on homework might be?”

Harry: “I don’t know.”

Mom: “Well, your teacher says 45 minutes a day is expected for 4th graders”.

Harry: “Ok.”

Mom: “So let’s set a timer. Do your homework, and we’ll check it together. After 45 minutes you’re done, even if we’ve only corrected part of it. But if you start fussing and complaining, I turn off the timer during the fussing. It only counts, and the timer only restarts when you’re working.”

Harry: “Ok. Let’s try it.”

(Discussion with the teacher ahead of time to give her a heads up on this plan is advisable, so she isn’t caught off guard when some of the homework is turned in uncorrected or even incomplete.)

 

Step Six: Create a hierarchy of specific recurring problematic situations, and tackle them from easiest to hardest. Don’t get stuck- keep moving up the staircase, while you gradually hand over the responsibility of self-regulation to the child by getting him to query/say to himself what you have been saying to him.

 

Thomas’s Case:

Mom and Thomas might sit down and come up with four or five common OCD’s Thomas displays, rank them according to how anxious/how hard it would be to stop doing each one, and work on them one by one, easiest to hardest, with a celebration/reward after each success. For example, Mom could create a staircase with dumping ice cubes on the lowest step, then sitting on every bench they pass by on the next step, then pulling off sticks from our neighbor’s bush on the next, and finally on the top step cutting up yard-long pieces of tape into tiny pieces before doing each page of homework, as these are all problematic OCD’s for Thomas.

For strategies on dealing with OCD’s see my previous blog entitled, “A Contemplative Walk… Working with OCD,” from 2013. The basic exposure/response prevention “homework” is for the individual to intentionally and regularly expose himself to the OCD or anxiety trigger by gradually increasing degrees (for example, if one is afraid of dogs, one would not immediately expose oneself to a huge German shepherd, but start out with a small, very tame dog or possibly even a picture or movie about a dog), and make himself stop (not perform the compulsion or fight/flight response) for increasing amounts of time. Each time he successfully prevents himself from performing the compulsion, the “stop muscle” in his brain (in the basal ganglia) gets stronger, and the OCD gets weaker.

 

Harry’s Case:

Mom: “Harry, how would you rank the things you have to do for school but make you feel anxious or overwhelmed, from 0 to 10?”

Harry: “Like what?”

Mom: “Like correcting your homework, reading a chapter from a chapter book daily, writing a report, or cleaning out your backpack?”

Harry: “Homework 6, chapter book reading 5, report 10!, backpack 4.”

Mom:” Ok, I put the four school tasks on four index cards in rank order of difficulty. I’ll give you all the support you need to get through them all, but we’ll work towards independence on the backpack first. Each time you master a card, we’ll do something really fun.”

Harry: “Can we go to Target for baseball cards?”

Mom: “That sounds good to me! And when you make it through all the cards, I’ll even get Dad to take you to a Angel’s game. So tell me what you know about keeping your backpack in order… ”

 

So there you are, CBT in a nutshell, or at least a flavor of it. CBT is a powerful, multipurpose tool, used successfully in a wide range of psychological disorders, including depression, anxiety, OCD, eating disorders, substance abuse, insomnia, posttraumatic stress disorder, personality disorders, trichotillomania (hair-pulling), tic disorders, and other repetitive behavior disorders. In Thomas’s case, we used CBT to work on OCD. In Harry’s case, we used it to develop a higher frustration threshhold. As parents, frontline and in the trenches, we need this tool.

 

A lot of CBT is commonsense. Teach your child to become more attuned to the body, recognize the physical symptoms of intense emotion and use deep breathing and muscle relaxation to ameliorate it. Address emotional dysregulation in its early stages while there’s still some frontal lobe control (ie ability to use his thinking brain). Teach him to become more self aware, both in monitoring his emotional state and identifying false, negative thinking. Help him learn how to replace it with true, positive thinking, and use a Socratic approach to develop the child’s multicausal thinking, giving him the freedom and support to brainstorm a variety of possible solutions and then to exercise judgment to decide upon a course of action. Show him how to harness motivation and reward to help execute those plans. Work systematically and persistently, from easier to harder, with the goal of transferring more and more control and responsibility to the child for his own emotional regulation. Set reasonable goals and expectations and make the steps as little as needs be for your child to experience success regularly with a reasonable, not heroic amount of effort.

 

CBT has got to be more effective than not knowing what to do, getting upset in reaction to our children’s crazed behavior, and acting out of frustration or trying to take over. So don’t be afraid to try it. Consider reading Dr. John March’s (2007) book “Talking Back to OCD,” or Dr. Anne Marie Albano’s book, referenced earlier. If you need more help, ask your pediatrician for a referral to a licenses psychologist or mental health provider experienced in CBT (you can ask if the therapist has any certification from the American Board of Professional Psychology or from the Academy of Cognitive Therapy). Things can only get better as you start moving your child in the right direction.

 

Disclaimer: CBT is only one tool in a parent’s toolbox. It is most appropriate to use on “crazed” behavior that may be primarily due to biologically-based.(meaning due to neurological wiring or temperament) negative emotion. But a lot goes into a parent’s decision that the emotion is irrational. Lots of times children get upset for very good, legitimate reasons, and those feelings need to be affirmed and their causes rectified, not extinguished with behavioral methods. Also some seemingly baseless negative emotions have deep roots in traumatic memories. You might need other tools to help you uncover and address the pain of these kinds of past experiences, such as psychodynamic or play therapy. Above all, there is no substitute for first and foremost listening to your child, and letting him know you care about all his feelings, rational or not.

Charles Schultz peanuts

 

[1] OCD stands for obsessive compulsive disorder. It is due to a brain glitch in which the individual has a recurrent false thought (like “there are always dangerous germs on doorknobs”) that compels him to perform a compulsion (like “I must wash my hands every time I touch a doorknob”).

[2] CBT stands for cognitive behavioral therapy. It is based on the assumption that thoughts lead to actions, and so if you repair the maladaptive cognitions or thinking, you can improve the behavior.

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“Neither defiance nor denial is of the least use here: one takes arms by learning how to negotiate or navigate a sea of troubles, by becoming a mariner in the seas of one’s self.” Oliver Sacks, 1990

 Peter was struggling this weekend. Couldn’t be left alone a second or would tear something up. Took out the sole of his shoe and ripped it into pieces in the time it took me to get to the kitchen  and back. Repetitively rifling through his basket of scrap paper he was allowed to tear. One of those days Peter was definitely uncomfortable living in his body. So we had to get out. “Carride, airplane!” Peter said over and over. We set out looking for any kind of change, doing something or being somewhere Peter could find calm in the storm.

Papa drove us to Descanso Gardens. Peter immediately started hunting for sticks, one after another, each of which he peeled and broke into bits. I asked for a map at the entrance (Peter likes maps, and they’re organizing), and struck a deal. “Ok, Peter, let’s try to get a grip on this tearing things up compulsion. Let’s exercise that frontal lobe inhibition and get you back in control.” “Okay, okay,” said Peter, still furiously dissecting a foot long branch he picked up at the entrance. “So here’s the map. You pick 5 places to go, and we’ll trace our way to each place on the map and then find a bench there. Make a comment on the scenery, earn a stick. No sticks in between. Sound like you can do it?” “Okay, okay.”

I stuck my finger at the entrance where we were, and Peter decided where to go. Getting to the first bench stop was the hardest. Peter was dying to pick up a stick, so we made the first distance very short. “Hold on Peter! First the comments.” I closed my eyes. “I feel a soft breeze.” Papa said, “I see the tall sycamores.” Peter typed, “I hear the water.” Then he made a dash for a stick. But gradually, as we made our way, progressing from bench stop to bench stop, the peaceful garden worked its quieting peace upon Peter.  The rests became longer, the drive for the sticks less immediate. Peter’s comments grew more elaborate. I ran a soft fern over one hand and had him feel the rough bench with the other. “I feel a soft fern and a hard bench.” “I see a big pile of rocks stacked.” Then wow! “I see a green wall of branches.” Peter was waxing poetic!

By the time we finished our last comment, the restless drive of that lower brain had been tamed by exercise of the body and mind in contemplation of the beauty of the garden. It’s loveliness and serenity for a time cast a spell over the mental monsters that plague Peter. This time the monsters had not won. Peter had ridden the storm of his tearing compulsion by confining it to a small place in a larger schedule, purposefully replacing it with other thoughts, turning his attention to the beauty surrounding him. For now the wave had passed, and we all felt refreshed and renewed, with hope in the power of mindful contemplation.

I exchanged glances with my tempest-tossed son, now at peace. “So who’s in control now, Peter or OCD?” “Peter,” he said with a smile. “All right, buddy! Give me that high five. You’re getting stronger, and the OCD’s getting weaker. And the doctor promised the more we practice, the easier it’ll get.”*

descansogardens.org

descansogardens.org

* So how does one work on OCD? What did the doctor mean by practicing?  Basically she meant the more Peter resists carrying out his compulsions until the obsessions pass, the more he experiences success in “riding the wave,” the more he’ll realize he does NOT have to obey the obsessions. It’s best to work on this in conjunction with  a formal exposure/response prevention program, in which you practice regularly under more controlled, less intense conditions.

You and your child need to first be able to identify the enemy, to recognize that it’s the OCD, not the child himself, who is the problem. OCD is a problem the child has, but can choose to work on and diminish to manageable proportions.

You explain how OCD is a brain miswire that makes you feel anxious unless you do something that doesn’t make sense or may be actually harmful. The child has to understand that the way to make the OCD weaker and for him to regain control, he needs to resist doing the compulsion (the dysfunctional behavior that the OCD is telling him he must do), and the need/desire to do it will diminish and eventually pass like an ocean wave that comes and goes.

It’s very hard to resist initially, but with each time you do, it gets easier and easier. With really strong OCD’s, you can’t just tell yourself “no.” Sometimes the best you can do is just somehow modify it, by engaging in it a shorter amount of time or repetitions (set the timer and tear up sticks for just 1 minute instead of 5), delaying when you allow yourself to do it (do the dishes before you get to grab a stick, or walk a block first), or changing up the way you carry it out (play a clicking sticks together pattern together with the parent before you get to tear it up). Peter’s favorite strategy is to “trick” the OCD by creating a whole schedule of things he has to do before he gets to do the compulsion, and by then often the need to do it has passed, and he doesn’t ever have to obey it at all.

Then you and your child make a list of OCD’s and start working on one at a time, usually starting with the less intense ones so the child experiences success which encourages him to keep moving up the list. But it’s most important for the child to have a lot of input into what he chooses to work on, and what’s most meaningful to him. This is critical for two reasons. One obviously is motivation. But the other is that we parents can have a hard time distinguishing between dysfunctional obsessional perseverative behavior and perseverative behaviors that may be serving as useful sensory accommodations for your child. For example, flapping and tapping may be a child’s way of figuring out where he is in space, and unilaterally insisting that  a child stop it may leave him with overwhelming feelings of disorientation which could make meltdowns inevitable.

Say your child chooses to work on a compulsion to tear off branches from bushes he passes. You might decide to start with setting the timer for 5 minutes he has to wait before tearing off a branch while gardening outside and pulling weeds or harvesting vegetables (and/or doing deep breathing exercises) instead. (It often helps to initially pick a substitute activity that physically exercises the body and/or one that keeps the hands busy such that doing the activity is incompatible with doing the compulsion. Eventually you want to work on helping your child learn to become aware of other interests and ideas he may have, and help him learn how to turn his attention to a different one of his choice. That is working on building what’s called “mindfulness.”) You gradually increase the timer till the child loses that crazed urge everytime he steps outside. You and your child agree to work as a team to strengthen his control over his OCD by deliberate practice, with you there to help keep him regulated with your calm redirection.

Your child works on his pre-planned “OCD homework” every day, working up to say up to 1/2 an hour twice a day (see John March’s excellent manual for parents and kids called, “Talking Back to OCD”), strengthening those frontal lobe inhibitions and basal ganglion “stop!” signal, while diminishing those OCD circuits by decreasing their use. Setbacks are normal and expected, so don’t let them upset you. You and your child can expect that if he gets up again, doesn’t give up and keeps trying, with consistent practice he will get gradually and eventually get more and more in control, and the OCD less. It’s important to realize that OCD is a condition one has, like diabetes, that seldom completely goes away, but can be managed successfully with consistent vigilance and habitual effort, such that a  functional, fulfilling life is possible. It’s just necessary  to make and take the time to deal with it.

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