Harming and Sexual Obsessions in Children Demystified
Some time ago, the most adorable and articulate 8-year-old boy walked into my office and proceeded to tell me, “ So you see, I am having these crazy thoughts. Every time I see a knife, I worry that I might, you know, do something to hurt myself. But, that’s crazy, because I have a really happy life!!!” As a result of these fears, this young man had started to avoid being around any type of sharp object and was compulsively seeking reassurance from his parents.
More recently, I met with parents who were concerned about their 12–year-old daughter’s constant confessing and reassuring seeking about sexual thoughts/images she was having (e.g., having sex with Dad, having sex with boys at school, even having sex with their family pets!!!). As a result, their daughter would no longer be alone with her Dad or their cat or dog and was starting to avoid being around boys at school all together.
Although these types of worries can be quite unsettling for both children and parents (and even pediatricians and many mental health professionals who are consulted), they are relatively common and easily recognizable OCD symptoms for experienced OCD therapists. Also, if treated appropriately, they generally diminish fairly quickly. Unfortunately, these types of symptoms are very often treated as generalized anxiety rather than as obsessive-compulsive and generally worsen as a result.
Before we talk about what appropriate treatment entails, let’s first talk about what doesn’t work. So, most parents (who have had any experience with these types of symptoms) have figured out that providing reassurance to their children does not work. In fact, it generally makes the symptoms worse over time. What kids have generally figured out is that strategies such as trying to will these unwanted thoughts or images away as well as seeking reassurance from others do not work. These attempts, in fact, also tend to make things worse over time.
In order to explain why these seemingly intuitive strategies don’t work, we need to understand conceptually how OCD works. So, as we know OCD is comprised of an obsessive component as well as a compulsive component. Obsessions are thoughts, images, or even just feelings that cause anxiety and are hard to get rid of. Compulsions are anything that one does either physically or mentally to get rid of the obsession and the anxiety associated with it. Compulsions do work (which is why people engage in them), but only temporarily until the doubt returns, leading to more compulsive behavior and increased fears over time. Bottom line is, compulsions don’t work long term. Because reassurance seeking and mental reviewing are both compulsive in nature, they don’t reduce anxiety long term…but, instead, actually feed the OCD. This generally leads to a whole lot of frustration particularly for parents who cannot understand why their rational responses just lead to more and more questions from their children. As a result, parents end up inadvertently helping the OCD, and when this backfires, often end up angry and frustrated with their children so that they are unable to offer support when needed the most.
Another strategy, mentioned above, that also backfires is trying to will the thoughts or obsessions away. Kids with these types of obsessions desperately try to block the thoughts out or run away from them to no avail. Why? Well, what happens if I tell you whatever you do, don’t think of ‘pink elephants’? Can’t do it, right? Nobody can (well, except for a very smart 11-year-old who told me he was thinking of ‘purple rhinoceroses’).
So, what does work? A treatment known as Exposure and Response Prevention (ERP) is the most appropriate choice for these symptoms. However, due to the sensitive nature of these symptoms, even experienced OCD therapists can struggle with how to appropriately engage kids in this form of treatment. However, the reality is these symptoms are just like any other OCD symptom and need to be treated in the same way.
Exposure means actively exposing yourself to the things that provoke your anxiety. Well, for the kids discussed earlier this meant gradually allowing themselves to be in the situations that provoked their worries (being around and using sharp objects, being around Dad and the family pets, etc.). This also meant doing some level of exposure to the thoughts themselves, by either just letting them be there (instead of trying to get rid of them) or by actively bringing them on through the use of a silly story or other creative means (e.g., making silly pictures of the child’s “gravestone” and hanging them all over). Humor and creativity are key when working with kids with these types of symptoms. Believe it or not, you can actually have fun with this treatment. My sessions are generally filled with tons of giggling!!!
In terms of Response Prevention (which is the voluntary blocking of any compulsive behavior), this means eliminating reassurance seeking, confessing, or any mental reviewing. Kids are encouraged to resist confessing/seeking reassurance, and parents are taught how to respond effectively (generally with some type of exposure) when kids slip up and confess or ask a question.
So you see, an OCD symptom is an OCD symptom is an OCD symptom and should be given equal treatment with ERP regardless of its nature. So, do not fret or fear if your child is experiencing harming and sexual obsessions…just get them into treatment and prepare to laugh!!!