Journal of Clinical Trials
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Experiences and Perceptions of Adolescents with OCD Amongst a Sample of Secondary School Teachers in Ireland

Sorcha Malone^1* and Joanne McVeigh^{1,2 *}Correspondence: Sorcha Malone, Department of Psychology, Maynooth University, Maynooth, Ireland, Email:

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Introduction

OCD: Definition, Diagnostic Criteria and Prevalence

Obsessive-Compulsive Disorder (OCD) is a chronic mental disorder characterized by recurring intrusive thoughts, impulses or images known as obsessions and repetitive or ritualistic behaviors known as compulsions American Psychiatric Association (APA). Compulsions can be physical or mental acts that an individual feels compelled to carry out to alleviate anxiety induced by unwanted obsessions. Although the nature of such obsessions varies in individuals, there are some common themes that often arise in cases of OCD, including contamination, symmetry, inappropriate or unacceptable thoughts (often sexual or aggressive), and harm (to oneself or to others). The diagnostic criteria, as set out in the Diagnostic and Statistical Manual of Mental Illnesses (DSM-5), include the display of either obsessions or compulsions, or both, which cause significant impairment or distress (or take more than one hour per day) and may not be attributed to the effects of another medical condition or substance.

One of the earliest studies on OCD was carried out by Lewis in 1936, which highlighted the need for a more systemic approach to studying ‘obsessional illness’ [1]. Until recently, OCD has been identified as an anxiety disorder, and it was not until 2013 that this changed when the DSM-5 introduced obsessivecompulsive and related disorders as a new section [2]. This section also includes body dysmorphic disorder, skin picking disorder, hoarding disorder, and trichotillomania.

An early study on the prevalence of OCD, involving a survey of five U.S. communities, identified OCD as one of the most prevalent mental health problems [3]. In 2014, OCD was also estimated to contribute significantly to the global burden of disease [4]. This condition, once thought to be a rare condition, may now be identified as one of the more prevalent disorders, with prevalence rates falling between 1 and 3 percent across countries [4,5]. Recent nationally representative studies have supported this finding and confirmed that the lifetime prevalence of OCD is 2%-3% [5-7]. However, estimates of the prevalence of this disorder vary, potentially due to variance in populations studied and/or the instruments of measurements employed.

Studies have suggested that the typical age of onset for OCD is between 18-29 years, with significant differences found between males and females [8]. According to the National Comorbidity Survey Replication (NCS-R), onset was found to be earlier in males (before age 10), whereas onset for females typically occurred during adolescence. Most recently the World Health Organisation has stated the age of onset typically falls between age 8 and 12 [9]. Some studies have suggested that the age of onset may be associated with different causal factors. For example, Nicolini et al., highlighted the role of genetic factors in early-onset OCD [10]. An association was also found between age of onset and symptom severity, with more severe symptoms presenting in those whose symptoms had an early onset [11,12]. This is a long-lasting disorder in which symptoms may last for decades, as demonstrated by longitudinal studies in both community and clinical settings [13].

One of the most robust findings in OCD research is its comorbidity with other disorders [14-16]. A meta-analysis conducted by Sharma et al., found that more than 75% of individuals with OCD present with comorbid disorders [15]. Mood disorders were found to be more prevalent in adults with OCD and anxiety disorders were more prevalent in children with OCD, while the prevalence of neurodevelopmental disorders was equal between both adults and children with OCD. A relationship has also been found between OCD and eating disorders, with approximately 18% of all individuals with an eating disorder reporting previous experience of OCD [17].

It is important to note that while this condition is classified as a ‘disorder’ in clinical contexts, many have argued against this categorization and have suggested that its symptoms fall along a spectrum of normal human experiences [18]. Research has shown that symptoms such as intrusive thoughts are not exclusive to OCD and that individuals without OCD may experience them from time to time with little to no feelings of distress [19]. However, it is essential to further investigate perceptions and experiences of challenging compulsions and obsessions to understand how to improve individual well-being and to provide supports where necessary.

Treatment

The treatment of this disorder can be approached in numerous ways, including therapeutic or pharmacological methods and combined approaches [20]. Cognitive Behavioral Therapy (CBT) is an effective approach to OCD treatment, with Exposure- Response Prevention (ERP) yielding empirical support [21,22]. This approach involves gradual exposure to obsessional triggers while refraining from carrying out compulsive behaviours [23]. The goal of this method is to gradually reduce the anxiety that these triggers induce by allowing the individual to see that their fears do not manifest when they do not perform their compulsions (Reid et al., 2021). Research demonstrates that ERP is one of the most effective therapies for the treatment of OCD across all ages [24]. Other studies have found success in other approaches including the use of medication, including clomipramine, fluvoxamine, fluoxetine and sertraline [25-28]. However, pharmacotherapeutic methods are not found to be more effective on their own relative to CBT [29,30]. Studies on the efficacy of combined-methods approaches involving both therapeutic and pharmacological methods have yielded mixed findings. However, a meta-analysis conducted by Skapinakis et al., found that the combination of both methods may be more effective than psychotherapy alone [31]. A meta-analysis by Mao et al. (2022) reported that while combined approaches to treatment significantly improve outcomes, it is not enough to suggest that medication enhances the efficacy of ERP [32].

OCD in childhood and adolescence

OCD is amongst the more common disorders in childhood and adolescence, with studies consistently reporting a prevalence rate of 1%-3%, across countries [38,39]. Furthermore, between onethird and two-thirds of adults with this disorder first experience symptoms in childhood [40-43]. Its presentation may vary slightly in children and adolescents. It has been suggested that compulsions are more easily diagnosed in children than obsessions. Moreover, the nature of obsessions may correspond with a child’s stage of development, with adolescents being more likely for example to experience religious and sexual obsessions in comparison with children.

While this is a relatively common disorder in childhood and adolescence, it is regularly misdiagnosed or undiagnosed [44,45]. This may be due to multiple factors. A study by Presta et al., highlighted that it may partly be due to an absence of egodystonia in childhood and adolescence, meaning that these obsessions or compulsions may not cause significant distress in a young person, as in an adult, and therefore may not be recognised as a problem [45]. However, there have been no recent studies that support this theory. In the case that the child does recognise these thoughts or behaviours as problematic, there are other factors that may prevent help-seeking. A study by Storch et al., found that bullying was a major issue for children suffering with OCD [46]. As a result of misconceptions and negative attitudes towards their disabilities, students with OCD are more likely to be excluded and bullied, which may induce a sense of shame, causing them to hide or suppress their symptoms [47,48].

Studies have indicated that OCD can cause serious academic and psychosocial impairment for young people [49,50]. Indeed, individuals diagnosed with OCD are 55%-62% less likely to progress beyond compulsory education, according to a study based in Canada. There is limited research on the ways in which this disorder may impact children in educational settings. However, a study by Pérez-Vigil et al., found that impairment was most significant at later stages of secondary level education [51]. Some areas affected by OCD in educational settings include school avoidance, school refusal and decreased academic performance.

The role of the teacher

Most children and adolescents spend a substantial portion of their formative years in school or another educational setting [52]. Teachers therefore have great involvement in a child’s life and may play a significant role in their development and overall well-being [53,54]. In terms of mental health, it may be argued that the parents or guardians of children play a more important role in identifying problematic behaviours or patterns. However, research indicates that teachers play a crucial role in recognizing and supporting students with mental health difficulties [55,56]. More specifically, in relation to OCD, a disorder known for its complexity and heterogeneity, it is possible that these behaviours might only manifest in a school environment and therefore go unnoticed by caregivers. Research has shown that early detection is crucial for OCD recovery and teachers. Factors that enhance or impede the ability of teachers to identify symptoms of OCD therefore warrant exploration [57,58].

Barriers to early detection

OCD is one of the most misunderstood disorders, as its symptoms are often stigmatized and mischaracterized in society. In the past, it has been viewed as a “joke condition” [59]. This may partly be due to its misrepresentation in the media, with the stereotypical person with OCD being painted as a “neatfreak” [60,61]. While often it is only the organisational- and hygiene-related aspects of OCD that people are aware and these can indeed be symptoms of the disorder, they do not fully represent the potential depth and impact of this disorder [62].

As highlighted by Vickers, misconceptions and lack of awareness about OCD may hinder accurate identification and access to appropriate support [56]. It may be possible that such misconceptions and lack of awareness impede teachers’ abilities to identify OCD in students. Studies have highlighted the importance of educating teachers on mental health problems and have outlined the role of teachers in symptom identification. A lack of training in mental health, however, may lead to missed opportunities for early intervention. By strengthening mental health literacy amongst teachers, they can encourage acceptance and understanding among students, aiming to reduce the likelihood of the peer exclusion and mistreatment of students with OCD. Education is therefore needed for teachers to equip them with the skills of detecting this disorder.

Are teachers educated about OCD?

In a survey study conducted in Canada by Froese-Germain et al., it was found that over two-thirds of teachers had not received any form of training or guidance on how to support students with mental health problems [55]. In addition, 97% of participants expressed a need for further training in this area. This study, however, examined mental health problems generally and did not specifically target teachers’ knowledge of OCD. Research on teachers’ understanding of OCD and their ability to recognise it in their students is extremely limited. However, in a study conducted by McGrath et al. (2023) with a sample of 274 teachers in Canada, findings indicated that teachers received limited training or information in supporting students with OCD, and participants reported low ability to detect the disorder [63]. Although some participants had received training on OCD, in these cases it was found that the training focused on medical details of OCD rather than more applicable aspects such as its presentation in educational settings. However, as this study utilized quantitative methods, it was limited in gaining indepth insight into the specific aspects of OCD in which teachers lack knowledge or understanding. Nonetheless, these findings suggest the need for more comprehensive training programmes and strategies for teachers in relation to OCD.

Research aim

Studies exploring teachers’ understanding of and ability to recognise OCD are limited. This study aims to bridge this gap in the literature by exploring experiences and perceptions of adolescents with OCD amongst a sample of secondary school (middle school/high school) teachers living in Ireland. The findings of this study aim to inform the development and design of future training programs to equip teachers with skills to accurately identify and support students with OCD.

Methodology

Participants and procedures

A qualitative, cross-sectional study was conducted, in which data were gathered through semi-structured interviews. Participants in this study were recruited through convenience and snowballing methods [64,65]. An advertisement was posted on Instagram, where individuals could register their interest to be interviewed. All participants were required to be above the age of 18 and currently working as a secondary school teacher in Ireland. There were 15 interviews in total, in accordance with qualitative research guidelines for small sample sizes [66]. Ethical approval for this study was granted by the Departmental Research Committee of the Department of Psychology, Maynooth University, Ireland.

Materials

An 18-item interview schedule was designed by the primary researcher, based on the research aim and a review of the literature (see Appendix 1). The interview schedule explores participants’ perceptions and experiences of OCD among students. Two interviews were conducted in-person, and the remaining interviews were conducted through MS Teams.

Data analysis

Data analysis was conducted using Constant Comparison Analysis (CCA), a qualitative methodology that facilitates the iterative comparison of data to develop grounded theories [67]. This approach enabled a systematic examination of participant interviews, allowing identification of key themes and patterns. Initial open coding was employed in which meaning units (extracts) were identified from the qualitative data to label significant concepts. These meaning units were then grouped into categories (themes) reflective of shared characteristics. As new data emerged, continuous comparisons were made with existing codes, leading to the refinement and integration of categories. Domains’ (superordinate themes) were then used to organise the categories. Note-taking provided a critical space for reflection, ensuring that the findings were firmly rooted in the data [68]. The rigorous application of CCA deepened the understanding of participants’ experiences and contributed to the formulation of a theoretical framework that addresses the complexities of the subject matter.

Reflexivity

Reflexivity plays a vital role in ensuring credible and insightful findings. It requires researchers to critically examine their own biases, experiences, and social positions, which can influence data interpretation. As Van Manen suggests, engaging in reflexive practices allows researchers to connect their lived experiences with the participants’ realities, enhancing the depth of understanding [69]. Lincoln and Guba advocate for reflexivity to establish trustworthiness in qualitative research, reinforcing the idea that self-awareness is crucial for ethical inquiry [70]. The researcher in this study, as a white Irish, female third-level student with experience of teachers at second level, incorporated reflexive approaches throughout the research to provide a nuanced perspective on teachers’ understanding of OCD.

Results

Illustrated schematically below are the domains and categories that emerged from this analysis (See Figure 1). Participants revealed their perceptions and understandings of OCD in relation to ten domains: Manifestations of OCD; portrayal of OCD in the media; comorbidity; prevalence and impact; OCD in the classroom; teacher training; role as teachers; perceived ability to identify and support; barriers to identification and support; and importance of awareness and education. The domains and categories identified are not listed in order of importance or any hierarchy.

Figure 1: The two major categories of NOVACs: Direct Thrombin Inhibitors (DTI) and Direct Factor Xa Inhibitors (DFXaIs) and their selective inhibitory effect on coagulation factors in the coagulation cascade.

Manifestations of OCD

OCD is characterized by compulsions

Ten participants described OCD as being characterised by compulsions and discussed how individuals with OCD may feel compelled to carry out a certain action, as exemplified by a participant’s definition of the disorder: “I would say it’s where somebody has a compulsion to do certain things” (P12 [participant 12]). Compulsions were commonly seen as out of the individual’s control: “You can’t really control the impulses” (P1) and which typically occur in response to an anxiety or fear: “The impulse to do something that’s kind of driven by…the anxiety behind if we don’t do it” (P5).

OCD is characterised by the need for cleanliness

Ten participants identified hypervigilance towards hygiene and cleanliness as being a symptom of OCD. For example, a participant stated: “maybe people are obsessed with cleaning” (P2). Seven of these participants specifically mentioned handwashing as a common behaviour amongst individuals with OCD, as illustrated by a participant’s comment: “I think the handwashing and the hygiene thing is I think it’s a big one” (P5). Other behaviours identified include wiping feet, washing the body, and having a clean home. As asserted by a participant: “Somebody who needs to have their house spick and span” (P9).

Affinity for organisation and structure in OCD

Eight participants described individuals with OCD as having an affinity for organisation and structure. Different manifestations of this organisation were identified by participants. For example, three participants discussed how individuals may like to order their things: “You might like to have everything in alphabetical order” (P10). Another participant detailed how individuals with OCD may like to organise and have a structure to their day: “preparing for things or whether it’s just having the structure to their day” (P2). One participant stated that this tendency for organisation may present itself “anywhere in their life in general” (P9).

Repetitive behaviours are characteristics of OCD

Twelve participants identified the repetition of tasks as a common behaviour in individuals with OCD. Multiple manifestations of this repetitive behaviour were identified such as light switching, repeating sentences, going in and out of doors, hand washing, rewriting words and closing doors, as illustrated by one participant: “If you see somebody where they have to repeat something… crossing the doorstep…switching a light on and off” (P7). Two of these participants stated that these were assurance-seeking behaviours, carried out to make the individual “feel maybe like less anxious or comfortable in a situation (P13).

Checking behaviours are characteristics of OCD

Five participants discussed how individuals with OCD may commonly partake in checking behaviours, as alluded to by one participant: “the constant checking of things” (P4). All participants gave examples of this behaviour. For example, one participant specified: “It’s things like making sure the door is locked” (P6). The most common manifestation of these behaviours that was identified was the checking of windows and doors, as demonstrated by a participant’s comment: “You check windows, you check sockets, you check the door” (P8).

People with OCD have a difficulty with change

Six participants identified individuals with OCD as having a difficulty with change. Half of these participants detailed how change may induce stress or anxiety for an individual with OCD: “If you go outside the routine, you get very anxious and stressed” (P11). Multiple examples of change were identified as being difficult such as changing plans or changing the placement of objects in a room: “even if you change cups into a different press or something” (P8).

Perfectionism and particularity are characteristics of OCD

Thirteen participants described individuals with OCD as being “very particular” (P2) about how they do things, and discussed their need for perfection in all that they do: “having to have everything perfect” (P14). Individuals with OCD were identified as having “perfectionistic tendencies” (P12) by six of these participants.

Low self-esteem in individuals with OCD

Five participants commented on how individuals with OCD may suffer from a lack of confidence, low self-esteem, and overall self-doubt. This is exemplified in a statement from one participant: “Very self-critical…towards oneself when they do something wrong” (P1). Notably, two of these participants spoke from experience of students diagnosed with OCD, who presented as such: “No-one that I’ve ever encountered with OCD has been overconfident or loud” (P4).

OCD is complex and manifests in various ways

Eight participants communicated that they understood this disorder to be complex in its manifestation, in the sense that it may differ from person to person: “it’s very complex and manifests very differently” (P1). Multiple participants expressed that two people with OCD may experience different symptoms, and something that bothers one person may not bother the other. This is exemplified by one participant: “Certain ones that they have that maybe other people with OCD don’t. Everybody is different…it depends on the individual” (P4).

Portrayal of OCD in the media

The media only portrays stereotypical symptoms of OCD

Six participants commented on the portrayal of OCD in popular culture and media. Participants identified cleanliness and organisation as being “stereotypical” symptoms of OCD (P2) or ones that may be more commonly known: “That is the one that is most commonly portrayed in the media” (P1). Three of these participants expressed that this portrayal was not a comprehensive representation of the disorder, as stated by one participant: “It’s not…like what you see on the television, it’s not that at all” (P6).

Comorbidity

OCD is associated with anxiety

Eleven participants identified OCD to be associated with anxiety. When asked if they could name any symptoms of OCD, nine of these participants named anxiety as one of them: “I would imagine anxiety might be a symptom” (P7). Whereas the other two participants identified OCD and anxiety as two cooccurring disorders. For example, one participant asserted: “I think again anyone with anxiety…they’re co-occurring conditions” (P11).

OCD is linked with autism spectrum disorder

Seven participants identified a similarity in symptoms of OCD and Autism Spectrum Disorder (ASD). As stated by one participant: “some of the symptoms you’re talking about there can overlap with autism” (P12). Three of the participants identified the two conditions as “co-occurring” (P11) and stated that many individuals who are diagnosed with ASD are also diagnosed with OCD. As alluded to by one participant: “having taught three students that have been autistic, they have been diagnosed to OCD as well” (P4). Two of the participants also stated that due to the overlap in symptoms, they may confuse OCD for ASD in a student: “I feel like there’s a crossover in some of the symptoms that I’ve seen with ASD as well, so I might incorrectly identify it” (P1).

Prevalence and impact

Increase in prevalence of mental health difficulties

Eleven participants communicated that they noticed a dramatic increase in the number of students presenting with a mental health difficulty. As contended by one participant: “The figures are so high, it’s more prominent than ever before” (P4). Participants described this increase as an urgent matter that needs to be addressed, as exemplified by one participant: “Nobody's talking about it but there's a mental health crisis, like serious crisis” (P12). Five of these participants also felt that due to this increase, it is important now more than ever to support students’ mental health: “We need to come back to…focusing on now more than ever we’re such a diverse classroom with children with like a variety of needs” (P5).

OCD is more common than we think

When asked about the prevalence of OCD, twelve participants believed this disorder to be more common than people may think. For example, one participant stated: “I would say it probably is quite common…I’d say it’s definitely there more than we realize” (P2). Participants expressed how they felt this disorder may commonly go unrecognised or undiagnosed: “I would say it’s quite common but just not recognised” (P1). Multiple participants gave potential explanations for this. The most common explanation given by four participants was that students may mask or hide their symptoms: “I think especially girls they mask” (P11).

Lack of awareness of the impact of OCD

Upon hearing a statement of some general figures and information on OCD, thirteen participants expressed how they were unaware of the potential impact that this disorder may have on an individual. For example, one participant revealed, “I didn’t actually realise that it could impact in so many different ways” (P8). Five of these participants expressed shock that this disorder could have such a detrimental effect on a person’s life: “The 50%, and 62% don't go on to, or it impairs them going on to higher education, that's, that's kind of startling that you know, nearly half of people with this, that's quite…that's…that's startling to me” (P2).

Lack of awareness of the prevalence of OCD

Upon being given some information relating to the prevalence of OCD, seven participants expressed shock at the commonality of the disorder, stating that they were unaware that it affected so many people. This is demonstrated by one participant’s remark: “It’s interesting that it’s one of the most common, like that’s mad” (P3). Four of these participants explained that their shock was due to the fact that they had limited exposure to OCD in the school setting: “I’m actually shocked when you think there’s 1200 students where I am…out of my experience of 15 years there I can only remember one, but you can be guaranteed there was probably a hundred” (P6). Conversely, two participants were surprised as they thought the disorder was more prevalent than the figures suggest: “I don’t know why it was I thought it to be more” (P11).

OCD in the classroom

Lack of experience with OCD in class

Ten participants declared that they had no experience with any students with OCD, as alluded to by one participant: “I actually don’t have any, I haven’t had any since I’ve been in school” (P13). Three of these participants voiced that there were a few occasions in which they suspected a student may have been struggling with the disorder. For example, one participant shared: “I just kind of suspected a little bit… One particular student…I probably needed to be more direct in my teaching…more concise instructions…not vary too much…clear manageable goals.” However, all of them stated that they were unable to say for sure that it was OCD. For example, one participant observed: “she definitely has tendencies, like you could see that a mile away, but I couldn’t say that she was actually diagnosed with this” (P9).

OCD impacts students’ academic performance

Five participants communicated that they had previous experience with students diagnosed with OCD. Each participant detailed how the disorder impacted the student’s academic performance. For example, one participant shared how the student “wasn’t able to complete the exam without his notes… If he wasn’t able to use his notes he’d get really upset” (P1). The participants identified multiple ways in which their student was affected by this disorder in school, including taking longer to write notes, being nervous around other students, having difficulty with changes in the classroom environment, and putting themselves under pressure to perform well. For example, one participant shared: “She would have put herself under massive pressure, like, with regard to learning, exams, work” (P15).

Teacher training

Limited training received on mental health support

Ten participants reported that over the course of their career they had received some form of mandatory training or information on supporting students with mental health issues. Half of these participants described this training as too broad, with no information given on specific mental health problems: “It was very like general kind of how to support a student who’s like going through a difficult time but not necessarily who was like struggling with like maybe a certain condition” (P1). The other half reported that they had received more in-depth training and information either in college or as Continual Professional Development (CPD) training: “mental health we would have had kind of seminars in college and we‘ve definitely had a few CPD hours here” (P2).

Teachers seek voluntary training

Nine participants expressed that they had educated themselves on how to support students with mental health issues either through voluntary training resources or through informal methods such as the internet. Six of these participants stated that they pro-actively sought out voluntary training courses in areas that they were interested in: “I would have done a bit myself…on autism and ADHD, anxiety, depression” (P13). The other three participants stated that they had used various websites to educate themselves on mental health: “I will log onto the aware.ie and you know I’ll kind of try and upskill myself… educate myself a little bit better for them” (P8).

No training received on OCD

Fourteen participants stated that they had never received any form of training or information on OCD throughout the entirety of their educational career: “never had any in-school training related to OCD” (P10). It was also stated by two participants that they had never seen any voluntary courses advertised for OCD either: “I don’t even recall a course in it being advertised” (P5). One participant, who had previously taught a student with OCD, stated that he was never given any guidance on how to support that student in class: “I have taught students with OCD before; we were never given information to support that student at the time. Like, what you’re working off is your understanding of it” (P12). Notably, the one participant who did report having previous training in OCD, stated that it was as part of a general course on neurodivergence: “the one on…neurodivergency really zoomed in on… OCD and how heavily it can be linked to autism” (P4).

Current training procedures are ineffective

Seven participants expressed that current training procedures are not sufficient methods of educating teachers on how best to support their students with mental health problems. Three participants stated that the recommendations and guidelines for supporting the mental health of students are constantly being updated and therefore the training that they previously received may now be less applicable: “you do something ten years ago, it’s changing all the time" (P6). They expressed that training needs to be continuous so that teachers can remain informed on how best to approach mental health problems in the classroom: “Follow-up training and so on needs to be because it changes every year something that you know something new has come up new statistics new ways of dealing with things” (P11). Two participants also discussed how most training is voluntary and that teachers aren’t always available for it: “You’re not always available and how many teachers that actually take that up as well?” (P9). The final two participants felt that the training they had received in relation to mental health was not applicable to the classroom environment: “Definitely the training but it has to be relatable to us” (P3).

Teachers’ Role

Teachers have more than an educational role

In relation to supporting students with mental health problems, 13 participants described their role as being one that goes beyond academic and educational duties. They each expressed belief that they played an important part in safeguarding student mental health, as exemplified by one participant: “Our role would be, you know, it would be to reduce any anxiety that the young person might have and … to reassure them and to offer whatever assistance they might need” (P7).

Nine of these participants outlined that they had a responsibility to make their students feel comfortable in school and ease any anxieties that they may have: “It’s our responsibility…Certainly if we can make a day go a little bit easier” (P6). Nine participants also expressed the importance of creating a safe environment in which students feel able to approach them with any issues or worries that they have: “I think it’s very important for teachers just to provide a really safe space for students to be able to talk to them openly” (P1).

Teachers need to be aware

It was communicated by eight participants that teachers have a responsibility to be aware of the diverse needs of students in their classroom, as illustrated by one participant: “It’s up to us obviously to first of all be informed and to know who’s sitting in front of you” (P6). Each of them stated that in order to be able to support students with a mental health problem, they first need to educate themselves on how the issue affects their student and what they can to do help: “Getting to know your students and knowing these things really helps in planning and helping them be more comfortable in my class” (P9).

Role of flagging concerns

Eight participants felt that they had a responsibility to identify when a student may be struggling and to flag any concerns they may have, as illustrated by one participant: “I would often have my concerns and if I have any concerns I’d go to a counsellor or I’d go to a Year Head and I’d often discuss it then” (P9). Half of these participants also detailed how they may play a significant role in initiating the process towards getting the necessary diagnosis. For example, one participant asserted: “So if I noticed that, I would flag it with our special needs coordinator and say like ‘is there a possibility for an assessment?’” (P4).

Perceived ability to identify and support

OCD is difficult to identify in students

When asked if they thought that they would be able to identify OCD in their students, twelve participants expressed that they would find it difficult. As explained by one participant: “I think that could be quite hard” (P12). Nine of these participants stated that they might notice symptoms of the disorder if it were a very severe case: “Like a severe case I would imagine I’d be able to see…but a mild case I don’t know if I would” (P9). The other three participants stated outright that they would not be able to identify the disorder. As communicated by one participant: “no, definitely not” (P15).

Teachers are unsure how to support students with OCD

When asked about their role in supporting students with OCD, six participants articulated that they were unsure how to support these students: “I don’t know, it’s a very hard question to answer” (P7). The two participants who had previous experience with a student diagnosed with OCD, voiced that they were unaware of how they could support that student and felt unequipped to handle it: “This was my first time actually experiencing it in a class. I wasn’t fully sure how to deal with that” (P1).

Limited knowledge on OCD

Seven participants expressed that they had limited knowledge surrounding OCD: “I actually haven’t a clue… I probably actually know nothing.” Three participants felt that this disorder is not commonly discussed, particularly in a school setting. As stated by one participant: “We’ve never heard of this before” (P3). Participants felt that their understanding of the disorder was not comprehensive. As alluded to by one participant: “It’s definitely not the full understanding and I will admit to that” (P2).

Barriers to identification and support

Teachers are not made aware

Six teachers felt that they were not always made aware of students’ diagnoses and were therefore unaware that they may need extra support. As contended by a participant: “In some schools, that’s not actually the case that the guidance counsellors might know and maybe the Year Head or whoever, but that actually doesn’t filter down to the teachers of exactly what the issue is” (P3). Two of these participants identified a probable reason for this. One participant stated that this may be because when students are being treated by external mental health services, teachers are not always told: “when they’re treated by CAMHS (Child and Adolescent Mental Health Services), we’re not necessarily given their diagnosis” (P3). Another participant stated that it depends on what parents are comfortable sharing with the school: “it depends on what the parents are comfortable with communicating to the school and…to the teacher…the parent might not want the teachers to know” (P12).

Not with students long enough to identify OCD

Six participants expressed that it was too difficult to identify OCD in the classroom as classes are short and teachers do not get to see their students for long enough. As stated by one participant: “I don’t think I’m around kids all day long to maybe see the symptoms” (P2). They felt that if they were with students for a longer amount of time, they may be able to recognise some symptoms of the disorder. As communicated by one participant: “If I only have them an hour a week I don’t know if I’m going to see them… If obviously I have them more…then maybe” (P9).

Harder to identify OCD in large classes

Ten participants stated that the size of their classes may limit their ability to recognise symptoms of OCD in their students. For example, one participant explained: “If I have 30 kids in front of me, I don’t know if I’m going to know one from the other” (P9). Four of these participants discussed how they might be able to notice symptoms if they were with a student on a oneto- one basis, as exemplified by one participant: “Maybe on a one-to-one basis you might kind of pick something up” (P15).

Importance of awareness and education

Training in OCD would be beneficial for teachers

When asked if they felt training in OCD would be beneficial for teachers, all fifteen participants responded that it would be beneficial. One participant stated: “Oh yeah absolutely… if any of the education bodies were to be able to provide a workshop or even if there were webinars provided by the education Centres that teachers could attend, that would be great” (P10). During various stages of the interview, without being prompted by the researchers’ question, six of these participants also expressed how they felt more information on this disorder would be beneficial for their teaching. For example, one participant stated: “I really would love to get a bit more like just education and be more informed on how it can come out” (P2). Participants expressed an eagerness to learn more, with one participant stating: “I’m going to go on and do all the research” (P5).

Teachers need to be made aware of students’ diagnoses

Seven participants stated that to be able to help and support students with OCD, they first must be told about students’ diagnoses. Participants felt that once they were given the necessary information, they would be able to plan accordingly and make accommodations where necessary. As communicated by a participant: “It’s good to be pre-warned. I think it’s very helpful if you know, important so that you can check in with them” (P11). Three of these participants expressed that it is the responsibility of management and post holders to make the teachers aware of these students: “It’s down to the SEN (special educational needs) coordinators there to kind of break that down to us as teachers on the ground” (P3).

More schools should provide resources and training for mental health

Seven participants communicated that not a lot of schools have a great support system in place in relation to student mental health. Participants expressed how more schools should provide mental health resources for students: “I’d say that every school in the country needs at least one fully qualified counsellor, if not two” (P12), and provide their teachers with training in mental health: “It would be brilliant to get training across the whole country” (P4).

Students’ well-being is important for learning

Six participants highlighted the importance of students’ overall well-being and how it may impact their learning. A students’ ability to learn was described as something that goes hand in hand with well-being. As alluded to by one participant: “Without well-being, you don’t have teaching and learning” (P3). All six of these participants opined that good mental health was necessary for students to reach their full academic potential. For example, one participant observed:

“Mental health and the holistic side of students is actually … more important than the academic. If they’re holistically supported and assisted, they actually will reach their potential… If we don’t have that, I think we’re missing out on a hell of a lot” (P9).

Discussion

The primary aim of this study was to explore experiences and perceptions of adolescents with OCD amongst a sample of secondary school teachers in Ireland. This study’s findings can be centered around two critical themes: Limited understanding of OCD and the need for targeted education and training in relation to OCD.

Limited understanding of obsessive-compulsive disorder OCD

The participants in this study demonstrated an overall superficial understanding of OCD, with the majority recognising a limited spectrum of symptoms including cleanliness, repetitive behaviours, organisation, perfectionism, and checking behaviours. Interestingly, participants’ understanding of the symptomology of this disorder reflects their observation of the incomplete portrayal of OCD in the media. While participants acknowledged that the symptoms that they were naming were the ones that were most represented, they were unable to name any others. This supports the observation, as expressed in the DSM-5, that compulsions are more easily recognised in children than obsessions. The DSM-5 notes that this is likely due to the fact that compulsions are more outwardly presenting than obsessions and are therefore more noticeable to parents and/or teachers.

Three participants were sufficiently aware to recognise that this disorder may be more complex than is commonly known and acknowledged the impact that it can have on individuals in terms of their mental health and well-being. Some examples of its impact that these participants provided included a lack of confidence and experience of anxiety. Those participants who understood the disorder to be more complex, still demonstrated a superficial understanding.

Almost half of the participants revealed that they had only ever recognised or observed OCD in students who also had a diagnosis of ASD, thus drawing parallels between autism and OCD. While there may be symptom overlap, as supported by previous studies on the comorbidity of OCD such as that by Sharma et al., OCD is not exclusive to people on the spectrum and may exist on its own [16]. The participants reported a feeling of confusion about symptoms of both disorders and that they were unable to discern between the two.

Only one participant in this study discussed experiences of OCD in a student with OCD (who did not have any other diagnosis), which is notable given the prevalence of this disorder, which is suggested to be between 1% and 3% worldwide. This suggests that students with OCD may be going unnoticed in schools, as the numbers of students recognised by the sample of teachers in this study do not align with estimated prevalence rates. One participant commented on this by saying: “I’m actually shocked when you think there’s 1200 students where I am…out of my experience of 15 years there I can only remember one, but you can be guaranteed there was probably a hundred” (P6) (PX).

Need for targeted education and training

Participants identified a need for further training in identifying and supporting students with OCD and identified gaps in their understanding of the disorder. Although the participants referred to pre-service training and CPD, they stated that all education and training were related to mental health in general and not specific disorders such as OCD. Indeed, the majority of participants (93%) reported that they had never received any form of training or information about OCD. This finding in relation to the lack of education and training regarding in OCD aligns with McGrath et al.’s findings (2023), which reported that teachers only received general training in mental health, but nothing that related specifically to OCD. It is important to note however that many students with OCD may be hesitant to open up about their struggles due to a fear of stigma, misunderstanding or unwanted attention, which creates challenges for teachers trying to support them.

It is imperative that this topic is approached with sensitivity and that a safe and non-judgmental environment is provided for students to freely communicate. Teachers should be educated on how they can simultaneously fulfil their role of identifying potential symptoms of OCD while respecting students’ privacy and autonomy. Each individual with OCD is different and therefore the most beneficial role that a teacher can play varies depending on the student’s needs.

Some participants identified issues with available courses, which may not be easily accessible for all teachers, stating that they are often at inconvenient times or are cost-prohibitive. Participants mentioned that some teachers are not motivated to upskill in mental health. There is a need for relevant mandated training in mental health and OCD, given that the teachers’ role extends beyond subject content delivery, as the findings of this study suggest. According to participants, teachers are tasked with providing a safe classroom environment for all students. Considering approximately two-thirds of individuals with OCD report severe impairments in daily life and the issue of bullying for children with OCD, there is a moral imperative to provide appropriate training for teachers. Participants identified themselves as the first point of contact for students who may be going through a difficult time, which further endorses the need for upskilling of teachers. As previous literature has demonstrated, teachers are pivotal in enabling students to access support, when necessary, no matter the issue. However, if teachers cannot identify OCD in students, they cannot refer to or provide support.

Notably, the results of this study suggest other factors exist that cause frustration within the system. Some teachers expressed a lack of communication whereby relevant information was not brought to their attention. Others mentioned that the short amount of time spent with students in class, coupled with large class sizes, limited their ability to identify OCD.

Conclusion

This study explored second-level teachers’ understanding of OCD and how the disorder impacts students in their care. Given the prevalence of OCD in children and adolescents and peak onset at 13-18 years of age, secondary school teachers will likely encounter students with OCD. Their ability to identify the disorder is critical for early detection and referral for treatment. This study reveals that teachers do not fully understand OCD and are not confident in their ability to recognize it in their classrooms, findings that are consistent with previous research.

This study demonstrates teachers’ awareness of the gaps in their knowledge and that this may adversely impact students’ mental health and well-being. The participants’ call for improved education and training chimes with previous recommendations and is justified given that studies indicate that OCD can cause serious academic and psychosocial impairment for young people. School avoidance, school refusal, and decreased academic performance are the outcomes for some students with OCD.

While this small-scale research is limited, and generalizations cannot be made, the study offers valuable insights and adds to the literature in what is an under-researched area. It is hoped that this paper will prompt more in-depth investigations into teachers’ and adolescents’ understanding of OCD. Such research would mitigate the dearth of literature on the topic and contribute to a richer understanding of how this disorder impacts young people. It would also help to identify the specific supports needed to effectively assist students with OCD in the school environment. As studies have shown that OCD may impact quality of life, it is imperative that every effort is made to help young people.

Recommendations

Based on the findings of this study, recommendations can be made to schools and policymakers to provide more targeted training and education for teachers around mental health and well-being, with a specific focus on mental health problems that students commonly experience, such as OCD. Additionally, given that the onset of OCD is most common between the ages of 13-18, further research into the impact of the disorder on students’ mental health and academic performance is recommended [71-73].

Studies on students’ experiences of teacher and school support would offer insights into the challenges that students face. Such research would also contribute to a richer understanding of the specific supports needed to effectively assist students with OCD in the school environment. It would also inform the design of education and training programs for teachers.

Limitations

Qualitative research can provide valuable insights, but it is not without its limitations. There are several limitations in this study, and those that may have impacted the findings are outlined here. The researcher attempted to navigate the challenges in the study design, data collection, and interpretation to mitigate the limitations and ensure the reliability and applicability of the findings. However, one significant issue with all qualitative research is the potential for researcher bias, where the researcher’s subjective interpretations can influence data collection and analysis. To mitigate the potential for bias in this study, the researcher used reflexive practice by questioning personal assumptions, judgements, and belief systems throughout the data collection and analysis process.

Additionally, the researcher relied on a small sample size of participants who were easily accessible. Teachers opted into the interviews, which resulted in responses from teachers from a small selection of schools within a particular geographical location. It transpired that most identified as female, and while the range of experience of teachers in the study was sufficiently broad, the school settings were similar. As such, the participants were not a representative sample and the findings cannot be generalized.

Moreover, conducting interviews virtually introduced additional challenges. Participants were offered a choice between in-person and virtual interviews and most opted for virtual. The occasional technical issues with the online interviews such as poor connectivity may have caused misunderstandings, as did the lack of non-verbal cues. These factors may have hindered the depth of interaction and rapport that can enhance in-person interviews, potentially limiting the richness of the data collected. Participants may also have felt less comfortable sharing intimate or sensitive experiences in a virtual setting, impacting the authenticity of their responses.

Furthermore, although outside the control of the researcher, there is a dearth of literature on this research topic. It is hoped, therefore, that this study will contribute to the body of literature in this area and prompt future research on teachers’ understanding of OCD. A mixed-methods approach using quantitative and qualitative approaches with a larger sample size is recommended. Care should be taken to ensure a diverse population of teachers from as many different school contexts as possible.

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