QUESTION
I have a 13-year-old son who is showing signs of anxiety and this is causing upset for him and for us. At mealtimes, he won’t use cutlery, bowls, plates or glasses that he deems “dirty”, and will go through the cutlery drawer, often laying the contents on the kitchen countertop, going through each one until he finds a knife, fork or spoon that is sufficiently “clean” for his use. He then repeats this routine for bowls, and so on. This can often take up to 15 minutes per meal.

My husband and I have been as casual and blasé as we can. We ignore it for the most part. If we do mention it to him at all, he gets upset, becomes defensive and won’t talk about it. 

He is also rubbing his hands a lot, and when I mention this casually to him, he says he is rubbing the dirt out from the cracks in the palms of his hands. He won’t go to the hairdresser or barber for a haircut as he is worried about being “seen”. He wants to get his hair cut, and I make the appointment, but at the last minute he backs out and I have to cancel.

My husband and I are at our wits’ end. We love our son to bits and we don’t want him suffering like this. We don’t know what to do next. He won’t engage with us at all in talking about what is going on, no matter how casually we approach it. It all seems very secretive and private.

ANSWER
While I am judging only from the details of a short email, it sounds like your son has symptoms of Obsessive Compulsive Disorder (OCD) which can be very troubling. It sounds like he is caught in a cycle of excessive worry (the obsession), for example, about things being clean, which he addresses through repeated rituals (the compulsions), such as constantly checking which cutlery is clean.

Depending on its severity, OCD can be very debilitating for a person and is not something they can usually stop by themselves. It sounds as if your son is also very embarrassed about what is happening and, like many people with OCD, he is finding it very hard to talk about what is going on for him, and the obsessive thoughts and feelings he is experiencing. OCD frequently occurs in the context of anxiety or perfectionism.

Getting a diagnosis
Usually, the first step in tackling OCD is to get an assessment and diagnosis. A good assessment will provide an understanding of your son’s symptoms and history of anxiety, as well as confirming whether his condition is best understood as OCD or another anxiety-related condition. Getting a diagnosis and putting a name to what he is experiencing should provide relief to your son, as well as to you, and crucially should provide a bridge to a treatment plan.

The best placed service to do this assessment is your local Child and Adolescent Mental Health Service, to which you can get a referral from your GP or sometimes from your son’s school. Alternatively, or if there are long waiting lists for a service, you may wish to seek support from a private mental health professional such as a psychologist (see psihq.ie) or a CBT psychotherapist.

Helping your son talk about what is going on
It is important to help your son talk about what he is experiencing in order to break his feelings of shame and isolation. If the indirect approach has not worked so far, maybe you could pick a good time to raise the subject directly. Say that you are worried that there is something troubling him and tell him he will feel better if he can tell you about what is going on. Acknowledge that you think he might be having obsessive thoughts about cleaning, and so on, and say how this can be really common among teenagers.

If he can’t tell you in the moment, don’t overpressurise him; say you are there later to chat. Give him the alternative of writing down what he is feeling or even texting or emailing you; this helped one parent I worked with. It also might be helpful to get a book, or some information online, that you can read together or that you can leave for him to read so you can discuss later.

Treating and overcoming OCD
Cognitive-Behavioural Therapy (CBT) is the most recommended approach for helping people overcome OCD. CBT first focuses on getting a detailed understanding of the teenager’s specific fears and behavioural patterns that make up their OCD. Then a goal is set with the teenager to tackle the problem by gradually exposing the child to their fears, for example, dirty cutlery, while helping them not to perform the compulsive rituals, for example, searching for a cleaner fork.

This is generally done as a gradual step-by-step process: for example, your son might be encouraged to hold a piece of “dirty cutlery” for a few seconds before working up to eating with one of them. CBT also focuses on helping children understand and challenge the unhelpful thoughts that underpin the OCD. For example, your son might avoid dirty cutlery because he believes that if he eats from a dirty knife he will die. Identifying this belief and then challenging it with reason and reality checking is an important process in CBT.

Resources
In helping a teenager overcome OCD, the role of a parent is one of a supportive coach: you become their number one supporter as they employ strategies to overcome the OCD. There are lots of great workbooks and resources online that go through CBT steps and other strategies that you can read with your son such as beyondocd.org/just-for-teens and Talking Back to OCD: The Program That Helps Kids and Teens Say “No Way” and Parents Say “Way to Go” by John S March.

Dr. John Sharry, Irish Times Newspaper, June 2015.  John writes in The Irish Times Health+ every Tuesday.
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