When Your Child Refuses Treatment

By Fred Penzel Ph.D.

In the ideal world, everyone’s child goes to treatment willingly does all their therapy homework comes to their sessions prepared and gets recovered in the shortest possible time Unfortunately we do not live in the ideal world One of my old grad school professors used to say that you could sum up most of child psychology in just one word – readiness Children do things when they are ready to do them – not necessarily when we are ready for them to do them One of those things they may not yet be ready to do is to tackle their OCD

Why do some children and adolescents refuse to go for or participate in treatment? There are several likely reasons:

Facing your worst doubts and fears can be intimidating and extremely anxiety-provoking even for adults so why should we expect more from children or adolescents? It is not unusual for children to lack insight into their own thinking Obsessive thoughts can seem very real and believable and can touch on topics that are extremely scary and threatening or even disgusting The technical term for such deeply held thoughts is overvalued ideation and this can sometimes be a factor in people avoiding treatment Even those who are motivated find this a complicating factor because the fear or disgust these thoughts generate can be so powerful
Younger children may have difficulty grasping that they have a serious problem or that there is a need to do anything about it They may view going to therapy as boring and pointless or taking them away from their playtime and friends.
Children for the most part aren’t able to see the future consequences of not recovering along with the possibility that their symptoms might become more severe over time.
Some children view having OCD as unfair and believe it is more unfair that they should have to work hard or do difficult things to get it under control They may believe that it should somehow just be taken away.
Adolescents can be very image-conscious and will often refuse to admit that they are having any kind of problem when such problems are severe and out in the open They may be very determined to not admit to the problem or may simply try to minimize it Pushing them to face things can often bring on denial and/or an angry reaction.
Some children can be very perfectionistic or very independent and will simply say that they will do it themselves when they feel like it and don’t want anyone’s help.
When some children discover what they will have to do to face their fears in order to get recovered they may balk and refuse to participate Their fear is that treatment will only make them worse It is because their anxiety is so strong to begin with that they just can’t imagine doing anything that might make it worse They also can’t imagine having to give up their compulsions – the one thing that has brought them any kind of relief from their anxietyven if that relief only lasted a little while.
The family has developed an ongoing pattern of enabling the child to avoid their fears by drastically altering the way they (the family) live and by assisting the child in performing compulsions (answering their compulsive questions reassuring them buying them such things as cleaning supplies doing rituals along with themtc.) This has allowed the child to sort of manage their fears and get by even imperfectly on a day-to-day basis without having to change or face anything dislikable I like to call this “becoming comfortable in their discomfort.”

Remember that you cannot directly control your child’s OCD in just the same way that you cannot make them at sleep learned. Only they can face their fears and do what has to be done The worst things you can do with a reluctant child would include:

Constantly nagging them to go for help and arguing with them when they refuse
Trying to physically force them to go to treatment
Threatening them if they don’t do something about their symptoms
Shaming them yelling at them or insulting them either privately or publicly
Punishing them for not getting help by taking privileges or favorite belongings away
Isolating them from the rest of the family or their friends
Offering them overly large rewards if they will only cooperate
Getting physical with them to try to prevent them from performing compulsions

I have never seen a child successfully threatened or punished out of their OCD but I have seen many unhappy children and families show up for treatment after this approach has failed If your child had a different chronic disorder such as asthma you would not threaten punish or shame them. These responses are demeaning and inhumane I also strongly believe that positive systems based upon rewarding good and desirable behavior are superior to those based upon punishment There are limits to how much you can restrict your child's life and take things away as a means of controlling them You may only create defiance and your child will soon realize that you really are limited in the amount of control you have over them Punishment will make your child better at avoiding punishment They may become more secretive about their symptoms out of a fear of punishment They will simply go underground with their thoughts and behaviors Other unwanted effects of threats shame and punishment can be to make your child angry and resentful and thus more resistant to change not to mention stigmatizing them and making them feel defective and unlovable

Obviously, you cannot stand by while your child’s health and safety are at risk No one would advocate that In such cases where you have a reluctant child or adolescent and they are not at serious risk you have several options.

First and foremost educating yourself about the disorder via books or internet articles written by experts or having a consultation with a therapist who is expert in OCD treatment.
You can at least inform your child that help is available and that you will arrange it for them at any time in the future should they change their minds All they will have to do is ask.
If the symptoms are not too severe and the child can function socially and in school despite them you could take a wait-and-see approach If the symptoms go on to become too limiting or obnoxious to the child they may change their mind about getting help.
You could try to create some motivation using incentives as part of a program known as contingency management (which will be outlined below).
If you are dealing with an adolescent you might provide them with some suitable reading material or web addresses that can allow them to educate themselves about their problem You might also be able to find articles by peers with similar symptoms that they can relate to personally.
Getting some counseling for yourself to be able to cope with your child’s reluctance and to perhaps get some good advice about how to overcome your own distress and impatience with it.
You might at least get them to agree to try medication if they won’t do anything else Most children won’t refuse meds and don’t generally see them as threatening in any way.

Having said all of the above when faced with a reluctant child the use of reward is clearly the most humane and logical approach Although such a child may not want any part of therapy at first when they see the potential for getting some things they really want they tend to become more interested I like to say that “Everyone has their price You just have to find out what it is.” This is best done via a reward-based approach called Contingency Management It involves creating motivation and encouraging children and adolescents to take part in their recovery themselves It is usually used as part of a therapy program To do it properly the therapist and child first draw up a list of potential rewards that can learned – usually about a dozen different desirable (and reasonable) items that are also agreeable to their parents These are not mega-sized rewards such as a car a dog or a vacation Acceptable rewards might include such things as (but not limited to):

Renting a favorite movie
A meal at a favorite restaurant
Receiving a reasonable amount of money
Picking out a piece of sports equipment to buy
A new videogame
Having their favorite meal prepared for them
A new piece of desirable clothing
Going to see a new movie

Together the therapist and child then make up a list of daily therapy assignments that they will agree to try working on for the next week and enter them onto a special check sheet that they have to fill in at the each day The understanding is that if they complete all their assignments for a given week they will then earn the right to select one item from their list of rewards Standards for how many days they have to be successful can sometimes be a bit laxer at first tonsure that they get a taste of earning rewards and to make them feel successful I have seen this work with children as young as four and as old as sixteen.

A further step you can take with a reluctant child or adolescent is a somewhat more tricky and complex one and one that you may needxpert advice about This would involve withdrawing the things you do tonable your child’s disorder (mentionedarlier) This is not something that generally speaking should be done suddenly or all at once in a cold-turkey way In therapy this is usually something that is negotiated between the therapist the child and the family It is usually done in a gradual way as well Cooperation is more likely if the child has some say in what will be happening in their lives They may already feel as if their lives are out of control and one way they deal with their anxiety is to try to controlveryone andverything around them Giving them a better kind of control can sometimes help win them over Also they are more likely to agree to something that is at least partly their own idea Obviously a therapist who isxperienced in putting things like this into practice will do this mostfficiently But what if you don’t have a therapist nearby or your child absolutely refuses to see one? You can still withdraw your participation in their compulsions but be sure to observe the following points:

One very important note Before you even start this you must consider just how severely ill or mentally fragile your child is If carrying out a program of this type is likely to drive them to do something desperate (such as threatening to harm themselves or others) then you may want to reconsider A child this seriously ill may instead need hospitalization within an OCD inpatient program A history of such serious and desperate behaviors on your child’s part would definitely be an indicator not to go this route More on hospitalization later This approach is really best for those with mild to moderate symptoms – not those with serious or drastic conditions.
Be very careful to tread lightly by not treating what you are doing as some kind of punishment for having the disorder Do not let anger enter into this in any way Discuss what you intend to do and why it is so important Explain that you are only doing this because you love them and are trying to help them You can also explain that their symptoms are making life very difficult for everyone else and that you have no choice.
Try if possible to negotiate a gradual withdrawal by drawing up a list of the things you will no longer do for them and have them pick which ones you will start with and in what order the rest will be done
Try to not give in to any anger tears pleading or guilt they may use to try to persuade you to not do this Don’t lose sight of why you are doing this and keep in mind the consequences of what will happen to them and the rest of the family if things don’t change
Once you have set up what will be done do not waver or make exceptions They really need to see your determination and that you will be consistent.
Make sure all family members are on the same page with all of this Complete cooperation from all of them is essential Even one enabler can ruin the system.

One interesting effect of successfully stopping the enabling of compulsions is that your child may end up being more motivated for treatment when they see they cannot and will never be able to create a semi-comfortable OCD life for themselves at home Taking away the hope that this can ever succeed may cause them to come face-to-face with their true situation At this point therapy may not seem like such a bad option to them.

So now to our last question What do you do when you have a very seriously ill child who will in no way cooperate with treatment and with whom life at home has become virtually unlivable? In such a case hospitalization may be the only good option left This is never an easy step to take for all who are involved and one that must be done with a great deal of care It is certainly something you should only consider when no other options exist Problems you may face could include

Many regions do not have good OCD inpatient programs for children or adolescents and going to one may involve traveling far from home and family This can be time-consuming costly and inconvenient.
Getting insurance to cover such a program (which can usually be quite expensive) may not be easy and may involve filing a series of strong appeals.
A child may view having to go to the hospital as a punishment and may become quite angry at the prospect.
Going to any hospital may cause an already anxious child to become even more fearful when faced with the unknown

Still despite all these potential problems you may simply have to brace yourselves and go through with it How you present going to a hospital program to your child and how you prepare them can make a lot of difference Some things you can do might be to:

Go over the positive benefits of going to the program
See if the program has any past graduates around your child’s age who might be willing to tell your child what it will be like
Reassure them that people at the program will be able to understand what they are going through and that they have helped many other young people

The program may have someone who will be able to speak to your child and give them a better idea of what it will be like and who can reassure them as to the positive side of going there In actuality these programs can be quite effective and after a number of weeks in such a program your child may well return home with a different attitude toward recovery and therapy and able to now work successfully with a therapist on an outpatient basis.

Anything else you can do?

See if there is a support group for family members within driving distance that you can attend If there are none then perhaps there are support groups for sufferers that will allow a family member to attend.
If there are no expert practitioners in your area you need to investigate the possibility of getting help via the phone or online face-to-face services such as Skype.
Explore further resources on the internet such as chat groups-mailer, estc.
Attend the annual meeting of the IOCDF Foundation to connect with the numerous resources there to network with other families and to hear what the experts have to say

Overall you need to do everything you can to free yourself from the negative effects OCD has had on your life your family members and the sufferer in your life.

When Your Child Refuses Treatment By Fred Penzel PhD In the ideal world everyone's child goes to treatment willingly does all their therapy homework comes to their sessions prepared and gets recovered in the shortest possible time Unfortunately we do