Dear Therapist:

About a year ago, our 9-year-old daughter started to engage in compulsive rituals.  She would have 1 specific ritual (such as checking that her heart was still beating) for a few weeks and then switch to a different ritual.  Right now, her specific ritual is sniffing is an unusual way.  This was/is not interfering with her performance at school or home, and she seemed happy overall, but we decided to take her to a psychologist who was recommended to us by a well-regarded source.  We felt that the rituals were coming from anxiety or OCD and clearly from some sort of distress.  However, the therapy was ineffective.  The therapist insisted that my daughter had specific thoughts before engaging in the rituals that were causing the rituals.  She said that the way to treat the rituals was by doing "brave challenges" with my daughter where we would talk about her specific fear that triggered the ritual, during which she could not engage in the ritual.  This did not stop the rituals, and we argued with the therapist that there did not seem to be any thoughts immediately preceding the rituals.  There may have once been a distressing thought that motivated her in the past to begin this ritual, but at this point, the rituals have become so ingrained that they are almost like a habit, "tic" or strong urge.    Our daughter does it without even thinking, almost like an urge to scratch a mosquito bite to relieve distress.  Some people may have specific thoughts before a ritual (such as a fear of germs that causes them to go wash their hands), but this did not seem to be the case with our daughter.  We stopped the therapy, because it did not appear that this therapist knew how to treat this specific OCD.  What is the proper way to treat such a problem?  What kind of therapist is best for this?  We are a little wary of therapy after wasting money and time with this therapist.  Also, this therapist wanted to tell our daughter that she has OCD.  We felt it was inappropriate at her age and would damage her self-esteem.  What do the panelists feel about sharing a diagnosis with a 9-year-old?   

Thank you for your help. 

Response:

I would generally agree that rituals begin with a fear of one kind or another. However, the unconscious mind does not necessarily do things in ways that make sense to our conscious minds. Although there may have been a fear that ultimately led to a particular obsessive thought and a compulsive action, this cannot always be easily identified. Specifically with regard to children, adults attempting to help identify the “logical” fear that caused an errant thought may be way off. As adults, our conscious minds typically try to make logical sense of our unconsciously-driven thoughts and actions. Due to the dreamlike and childlike nature of our unconscious minds, we are often wrong. Certainly when we attempt to make sense of a young child’s unconscious fears, we can easily be barking up the wrong tree.

This isn’t to say that there is no benefit to identification and challenging of a child’s fears, whether conscious or unconscious. Children often have fears that, when older, they recognize were not realistic. Helping a child to identify these early on, and explaining to them why their fears are unfounded, can help them to let go of these. Nevertheless, there are times when identifying a causal fear cannot be easily done—and times when the fear has been so dissociated from the ritual that the ritual now stands on its own.

Assuming that your daughter does in fact have OCD, there may have been a fear that led to a thought (perhaps obsessive), which in turn might have led to a ritualistic action. However, at some point—perhaps especially in kids—the thought aspect often disappears, leaving only a sense of fear and an associated action. Many times, the action is used to gain a sense of control, and to thereby reduce the fear. Over time, the fear itself can be repressed, leaving only the ritual itself. When this occurs, working on reidentifying the initial fear can be helpful—but can be difficult or impossible with young children.

Additionally, there may never have been a directly-related fear, in which case the ritual may make no logical sense to an outside observer—even if they were privy to the original fear and its associated action. Also, as time passes compulsions can become increasingly more generalized, so that a particular ritual may not be in any way lead back to any current anxiety.

For example, let’s assume that your daughter initially had a fear of death. This may have led to the obsessive belief that her heart might not be beating, in turn leading to constant checking. Let’s further assume that at some point this may have stopped calming her, or her fear of death became connected to other parts of her body. At this point, she could have chosen a more general way of controlling her fears—sniffing. In this theoretical situation, it could be very difficult to identify the fear.

Going on our above assumption, fear of death is a common anxiety. One reason for this is the unfathomability factor. We don’t have a good handle on what death is, how it feels, or what happens after. This uncertainty can easily breed anxiety. For children especially, not understanding what death is, and therefore not having a clear idea of what they should be afraid of, can lead to fears that they cannot put their fingers on. Ritualistic behavior can become their way of controlling this inexplicable fear.

Sometimes, however, there is one particular underlying fear that is at the root of many obsessive thoughts and rituals. If that fear can be identified and explored, the resultant problematic thoughts and behaviors can be alleviated. I would recommend that you find a therapist who specializes in pediatric OCD who can help you to resolve this issue from more than one angle.

There are many factors that can help lead to a decision as to whether to share a diagnosis with a nine-year-old. These include the way in which it is described and by whom, the child’s level of maturity, and the degree to which they already feel that there is a problem. A competent child therapist can help you to determine the appropriateness of—and the method of—disclosure. Regardless, the decision should not be the therapist’s alone. Neither should their reasoning be based on a general belief that children should—or should not—be told of any particular diagnosis. Rather, there should be a thoughtful, in-depth discussion as to the benefits of sharing or withholding the diagnosis with your particular child.

-Yehuda Lieberman, LCSW

 psychotherapist in private practice

 Brooklyn, NY

 author of Self-Esteem: A Primer

 www.ylcsw.com / 718-258-5317

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