In May, a 15-year-old boy set up a socially distanced visit with a friend. They met on opposite sides of a sidewalk — a full six feet apart — and talked.
But when the teenager returned home, he brought with him a new set of Covid-19 fears, according to John Duffy, the boy’s therapist and a child psychologist in Chicago. How could he be sure six feet was a safe distance?, the teenager wanted to know. He began washing his hands more frequently. He stopped touching countertops. And he hasn’t wanted to see friends since.
The pandemic has understandably intensified our need for good hygiene and safety precautions. But for some children and teens, these precautions have crossed the line from careful to compulsive. And for parents, it can sometimes be hard to distinguish between a reasonable reaction to a very real threat and something more concerning.
There’s little data available yet on the toll the pandemic has taken on the mental health of children. But Eric Storch, an expert on obsessive-compulsive disorder and a professor at the Baylor College of Medicine, said calls to the university’s O.C.D. program have jumped significantly, by about 25 percent, since March. He attributed it in part to telemedicine improving access, and in part to worsening mental health concerns. Dr. Duffy said the number of his patients experiencing O.C.D.-like symptoms has tripled during this time.
About 500,000 children and teens in the United States have obsessive-compulsive disorder, according to the International OCD Foundation.
Obsessive-compulsive disorder has two main components. Obsessions take the form of uncontrollable thoughts, urges, feelings or uncomfortable sensations. Compulsions are behaviors repeated over and over. These can include excessive handwashing, showering or sanitizing, but also checking things, putting things in order, tapping, touching, seeking reassurance or asking the same question repeatedly.
“The key in O.C.D. is this functional relationship between the two,” said Jennifer Freeman, director of research and training for the Pediatric Anxiety Research Center at Bradley Hospital in Rhode Island, and an O.C.D. specialist. The compulsion neutralizes the worry, but the relief is often short-lived, “so obsessions come back, ritualizing seems like the only answer, and a vicious cycle is created.”
O.C.D. is far more complicated than germs and handwashing. Obsessions can be about dirt, germs and illness, but also about self-injury or thoughts of harm coming to oneself or one’s family, or the world. And not all young people with the disorder are suffering in ways related to Covid. Interestingly, Dr. Freeman said, many kids who were in treatment for O.C.D. before the pandemic feel uniquely equipped to handle the stressors of this time. “They’re saying, ‘This is how I’ve always felt. Now the rest of the world understands.’”
Still, many kids are “suffering terribly, and suffering more so because of the pandemic,” said Dr. Freeman, who is a professor at the Warren Alpert Medical School of Brown University. For them, if their schools are opening this fall for in-person classes, leaving the house and going back to school “is going to be really hard, and that’s real.”
For teens with Covid-19 anxieties, being with friends who are more cavalier about risk is especially difficult, Dr. Duffy said. “I’m working with kids who are super conflicted. They don’t want to miss anything, they don’t want to seem weird, and yet they are very focused on fear of transmission. And there isn’t much space for them to express that.”
So how should parents address their kids’ fears and behaviors? How can they tell the difference between a reasonable response to a dangerous virus and something that might require treatment?
Look for disproportionate fear
It makes sense to be cautious, but with O.C.D., you’re disproportionately afraid, said Tara Peris, co-director of the Child O.C.D., Anxiety and Tic Disorders Program and an associate professor at the University of California, Los Angeles. Parents should look for behavior that falls outside their family’s norms and the guidelines set by the Centers for Disease Control and Prevention.
The C.D.C., for example, recommends washing hands for 20 seconds with soap and water after being in a public place. “If somebody moves into the realm of washing their hands 20 to 30 times a day, or if they’re spending 15 to 20 minutes when they do wash, or they can’t get out of the bathroom, then they’re clearly more worried than they need to be,” Dr. Peris said. “I’m interested in whether kids are following instructions around them or whether they’re washing to relieve distress, and whether that need is expanding over time or building and taking on a life of its own.”
If it’s affecting family life, friendships and a person’s ability to do schoolwork, those are red flags, Dr. Peris said.
Trust your instincts
One complicating factor, Dr. Duffy said, is that it’s difficult to assess whether a person’s basic functioning is disrupted when the pandemic itself is disruptive to basic functioning. We’re working with a modified baseline, he said.
“What I tell parents is trust your radar,” he said. “If your child seems off emotionally, or raw or fragile in a way you wouldn’t expect, or significantly different than peers or siblings, then you won’t regret bringing a professional into the situation.”
The most effective approach for those with mild to moderate O.C.D. is cognitive behavioral therapy with exposure response prevention, which involves gradually introducing a person to the thing that scares them without giving in to rituals, Dr. Storch said. And the good news, he said, is that this treatment is effective at reducing symptoms more than 75 percent of the time. In more extreme cases, these therapies can be paired with medication.
Lara Koelliker, who is 18 and has been treated for O.C.D. since age 8, said she had severe symptoms for three years before finding a therapist who specialized in exposure therapy. The treatment helped her manage her symptoms by giving her coping mechanisms, she said.
“I’ve learned how to sit with my uncomfortable feelings, and I don’t give in to my compulsions,” she said. “Now the part of me that has been equipped with all these strategies jumps in.”
Therapy on Zoom
Many therapists are using video calls to treat patients now. And being inside a patient’s house, virtually speaking, can be useful for exposure treatment, as home is often “where O.C.D. lives,” Dr. Freeman said. Some kids, for example, have fears involving contamination from pets, family members, or parts of their house.
“On Zoom, I can say, ‘Can you show me that room? Can you show me that couch? Do you think you can sit on that couch? Can we do it together?’”
Beyond therapy, parents’ top priority needs to be listening to their kids, Dr. Freeman said.
“Validate, validate, validate what the kids are feeling,” she said. “And be willing to have difficult conversations that stir up anxious distress in all of us. It’s really important not to tell a child they shouldn’t be sad, anxious or upset. That invalidates the emotions they’re feeling.”
Address school anxieties
Young people anxious about returning to school “should be encouraged to express their anxieties, and parents and school personnel should not dismiss them,” Dr. Freeman said. It’s important that students understand that some school rules may be more strict than the rules at home to accommodate more people. They should also know, she said, that it’s possible to feel simultaneously anxious and excited about going back.
Dr. Duffy suggests that students whose schools are opening do two things before school starts: Create a plan with a school counselor or adviser for when they’re feeling anxious in real time, and set up a walk-through of the campus with a staff member so the child can become familiar with any Covid-related changes, such as partitions in the classrooms or tape on the floor to maintain social distance.
“The schools in my area are offering this option,” he said, “and it’s alleviating a lot of fear by providing some sense of familiarity.”