Most of us have little rituals that we perform throughout the day that either make us feel more comfortable or stop us forgetting an important task. An example of this could be: we check the lights, windows and doors of the house in a particular order before going to bed at night. If we fail to follow the order then sometimes we feel compelled to go back and redo it in case we have missed something. It may be that we like to take our coffee break at a particular time, sit with the same people in the same chairs and use the same mug. This helps us to feel that during stressful times there are some things that do not change.
While these rituals comfort and reassure us, sometimes they can become intrusive, annoying or even disturbing to us if the compulsion to carry out a ritual is so strong we cannot settle unless we have completed it in a particular way. This is when we might call our little habits or rituals obsessions or compulsions.
Repetitive intrusive thoughts or impulses are often referred to as obsessions. Compulsions usually refer to actions/behaviours that a person feels they are driven to perform by their obsessive thoughts. These obsessive thoughts and compulsive behaviours are usually only a problem when they are causing disruption to an adult or young person’s life and causing them or others a significant level of distress. In other words, when the ritual has become unhelpful and is taking over their life.
The most common obsessive thoughts are:
- Excessive worrying that something terrible might happen.
- Counting or repeating words and phrases.
- Intrusive or disabling self doubts.
The most common compulsions are:
- Excessive cleaning.
- Repetitive checking.
- Ritualistic touching, e.g. light switches, door handles, etc.
- Hand washing.
- Arranging objects such as toys, books, etc.
- Skin picking and hair plucking.
Obsessive thoughts and compulsive rituals can be troubling to adults, children and young people if they start to take over their normal lives and cause them significant distress. Although sometimes people are not aware of reasons for their obsessive and intrusive thoughts or habits, often it is an irresistible fear that if they do not continue with these then something dreadful will happen or that they are losing control of their mind.
Troubling obsessions and compulsions have been reported in children as young as 5 years old. Studies suggest that approximately one teenager in every hundred will experience significant problems with obsessive thoughts and compulsive rituals, although this figure may be higher due to the embarrassment or secretive nature of some of these. They tend to be more common in young people when another family member has a similar problem, so it may be that other family members have experience of similar difficulties.
Children and young people are more likely to experience these kind of difficulties when they are under stress or during significant change in their lives, for example because of bereavement, exam stress, parental or family discord, or social isolation. They are more common in young people who worry a lot or are anxious. A child or young person may be very secretive and embarrassed about their thoughts and rituals, fearing others will think them 'crazy'.
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How to recognise when a young person might be struggling with obsessive thoughts or compulsive rituals and behaviours:
- Are they taking much longer to complete normal tasks such as getting dressed, washed or getting ready for bed?
- Are they taking longer to complete work in school? Do they appear to take longer to get started on a task or do they appear to be anxiously re-checking work?
- Is the child or young person very concerned about putting things such as toys in a certain order?
- Do they show or describe an excessive fear of dirt and germs?
- Do they appear to be continually repeating particular behaviours like touching things such as light switches or door handles?
- Do they become very upset by disorder and mess?
- Do they complain of thinking about certain things like words or numbers all the time?
- Are they showing excessive concern about order and symmetry?
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These behaviours can be very difficult for those around the young person to understand and deal with. If you respond only to your own feelings (for example irritation, frustration, anger) your response is unlikely to be helpful to the young person. It is therefore important to separate your own unhelpful feelings from your response.
For more advice, see section on being aware of yourself and your own response.
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- Be aware that the most common misconception of young people who have obsessive thoughts and compulsive rituals is that they need to keep thinking or doing the ritual in order to feel better. In fact, stopping the obsessive thinking or behaviour is the only thing that will make them feel better in the long term.
- Remember that the young person may feel frightened and embarrassed by their thoughts and rituals so approach them sensitively and in private if possible.
- Encourage the child or young person to describe their fears and rituals but don’t expect them to be immediately forthcoming. For more information, see section on counselling techniques.
- Find out how intrusive and disruptive the thoughts or rituals are and find out what areas of their life are affected; for example how often and for how long these thoughts or rituals have been troubling them.
- Keep information about the young person’s problems as private as possible, only sharing information with those that the young person has consented to and who can be helpful to them.
- Enquire about any stressors in the young person’s life such as bullying, exam stress, or family discord.
- Reassure them that intrusive thoughts and rituals are fairly common and that we all experience these to a greater or lesser extent. Possibly give an example of your own life, like checking before bed. Do not trivialise their own experience.
- Explain that you understand how difficult it is to control these thoughts and behaviours.
- Using language appropriate to the child or young person’s age, explain to them that continuing to act on their thoughts by carrying out rituals tends to encourage the thoughts or rituals to become stronger and more difficult.
- If appropriate and with the young person’s consent speak to their parents or carers to gain information from them and their support.
- Teach relaxation techniques. However, relaxation should not be used at the particular times of day when the young person is trying to avoid the ritual. This is because the relaxation could then become part of the ritual in itself.
- Encourage the young person to do their rituals less often or for shorter periods and give them support whenever possible to do this.
- The young person should be encouraged to experience feelings of anxiety, not to try and block them out, because these feelings will subside naturally when they are being supported by you to stop carrying out their ritual.
- Try and build up the young person’s confidence that they have the ability to avoid the thoughts and rituals by getting them to focus on times when they do not occur. For more information, see section on solution-focused techniques.
- With younger children consider using a behaviour chart to help encourage and motivate them. For details, see section on behavioural techniques.
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- Do not ridicule them or embarrass them about their rituals.
- Do not encourage the young person to continue to do the rituals even if they appear to be making them feel better, as in the long term this makes the problem worse.
- Do not try to physically force or punish them for doing their rituals.
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- If the child or young person is experiencing extreme distress and their thoughts or behaviours are seriously interfering with their normal day to day functioning, e.g. they are unable to get to school, or the ritual is causing serious eczema on their hands through washing.
- If their symptoms continue to increase in spite of your own interventions or they continue for more than four weeks without any sign of improvement.
- If the young person informs you of any information you are not experienced to deal with such as sexual abuse or suicidal thoughts or ideas.
- If the thoughts or behaviours occur in combination with other concerning behaviours that you believe require a more specialist assessment, for example tics or depression.
You should get in touch with your local health centre or hospital to obtain a contact number for the appropriate children and young people's mental health specialists.
Remember - you can contact your local mental health specialists for a number of reasons, for example:
- For advice on how to make a referral about a named child.
- For advice about whether or not to make a referral (it is normal practice to seek this advice without naming the child in the first instance).
- For advice about what to do (once again there should be no necessity to name the child).
By not naming the child you are protecting their right to confidentiality. This method of seeking advice also has the advantage that you do not need to get anyone’s consent in advance of your contact phone call.