by Ana Pérez-Vigil, MD, David Mataix-Cols, PhD & Lorena Fernández de la Cruz, PhD

This article was initially published in the Summer 2018 edition of the OCD Newsletter

 Those who know children with obsessive-compulsive disorder (OCD) are aware that many of them struggle with school work.

 Obsessive-compulsive disorder (OCD) often starts in childhood or adolescence and can be chronic. Obsessions and compulsions, the landmark symptoms of the disorder, are highly distressing and time consuming. This can have a major impact on the child’s ability to concentrate and benefit from school. For example, individuals with contamination fears may not be able to sit in the classroom or may have to constantly visit the restroom to perform hand-washing rituals. Other common rituals include the need to re-read or re-write sentences many times, which makes learning slow and frustrating. School attendance may be poor, and children with severe symptoms may be removed from the education system altogether. It is not uncommon for families to arrange homeschooling for their children in these circumstances.

Clinically, we also observe that it is difficult for young people to return to school even if they have had a successful treatment for their OCD symptoms. These difficulties do not only apply to school-aged children, but can also affect young adults who are at college or university. As a consequence, some people with OCD may have fewer chances to enter the labor market and have a high-paying job.

Despite these clinical observations, it has been difficult to quantify to what extent education is impaired in people with OCD as a group. Surprisingly, the topic of education has been poorly studied in the OCD field. Methods used by researchers in previous studies had a number of potential problems that made interpretation of their findings difficult, such as:

  • small sample sizes;
  • study designs that only looked at a “snapshot” of data, rather than following subjects over time;
  • retrospectively collected self-reported or parent-reported data;
  • and insufficient control for variables other than OCD that may have influenced a subject’s educational attainment.

In this IOCDF-funded study, recently published in JAMA Psychiatry, we set out to investigate the impact of OCD on educational performance at the population level.

Using information from the unique Swedish national registers allowed us to examine educational performance at the population level, giving us more precise information than we could obtain from just looking at a subset of people and drawing conclusions about what we observed in them. These registers contain information on all Swedish inhabitants regarding all medical diagnoses given in specialist care, including OCD, as well as socio-economic information, including every person’s official school marks from compulsory school and the highest level of education achieved during their lives. By merging these various official registers, we were able to compare the academic performance of more than 15,000 Swedish people diagnosed with OCD with more than 2 million people without the disorder. The results clearly confirmed the clinical observation that OCD is associated with pervasive academic underachievement, not only in school-age individuals, but also across a person’s lifespan.

 The education system in Sweden differs from that of the United States in a few ways. Swedish students attend “compulsory school” from ages 6 to 16. After compulsory school, most students move on to three years of upper secondary education, ending for many at the age of 19, although some students continue for longer. Students may then continue on to university and post-graduate education, as they do in the American system. We observed that students with OCD are significantly less likely to pass all courses at the end of compulsory school, less likely to finish upper secondary education, start a university degree, finish a university degree, and finish postgraduate education. On average, persons with OCD were approximately 40-60% less likely to complete each of these measured educational milestones. The association between OCD and educational attainment was global and not confined to any particular school subject. We found that people with OCD were more likely to fail every single course/subject at the end of compulsory education, including each of the core subjects (mathematics, Swedish, and English), compared to those without OCD. Additionally, we found that academic underachievement was worst in students who were diagnosed with OCD before the age of 18 — in other words, the earlier the onset of the disorder, the more pronounced the academic impairment.

 Based on a sample of more than 15,000 people with OCD, we showed that the disorder is associated with global academic impairment, spanning from compulsory to post-graduate education.

To rule out the possibility that factors other than OCD were explaining the students’ impairment (such as socio-economic status, parental education, parental mental illness, neighborhood, or genetic factors that are shared between siblings), we compared the educational performance of individuals with an OCD diagnosis with that of their unaffected full siblings. This design automatically controls for most of the above-mentioned variables, since we assume that both siblings (one with OCD, one without OCD) have been raised in the same environment, and share a common genetic background (full siblings share the same mother and father and approximately 50% of their genes). The results were clear: siblings with a diagnosis of OCD were still more impaired than their unaffected siblings, suggesting that the educational impairments are not explained by familial factors but, rather, are a likely consequence of the OCD itself.

We further wanted to rule out that these results were not merely explained by the presence of other psychiatric conditions or early-onset neuropsychiatric disorders such as attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders, or Tourette’s disorder, all of which frequently coexist with OCD. Excluding individuals with these comorbidities from the cohort resulted in largely unchanged results. While associated comorbidities may further contribute to worse educational outcomes in persons with OCD, it appears that the OCD itself is driving most of the impairment.

 Treating patients with OCD at early stages may increase the likelihood of progressing to higher educational levels.

The main conclusion of our study is that OCD has a pervasive and profound impact on education across all educational levels, particularly when it has an early age of onset. While the results are perhaps unsurprising, and somewhat disheartening, they provide the first objective quantification of these negative outcomes in OCD. We see this as an opportunity to raise awareness about the very real impact that OCD has on the person’s function. However, the really important question is, what can be done to improve these outcomes?

 First and foremost, receipt of evidence-based treatment (cognitive-behavioral therapy with exposure and response-prevention and/or serotonin reuptake inhibitors) is likely to reduce the risk of school underachievement in persons with OCD, as has been recently suggested in other disorders like ADHD. Hence, a clear priority is to improve the detection, diagnosis, and access to such evidence-based treatments.

 Second, educating teachers to detect and manage OCD in the classroom is important. Early detection in the school setting may lead to an appropriate referral to the school psychologist or mental health services. Learning strategies on how to manage OCD in the classroom, such as allowing frequent breaks or being more flexible with timed tasks where persons with OCD may struggle, such as exams, can make a difference. For those who are out of the school system altogether, return to school programs need to be put in place; in our experience, treating the symptoms of OCD may not suffice. If families, schools, and mental health professionals work together, these children and young adults have a good chance of fulfilling their educational potential.

This work was supported by a research grant from the International OCD Foundation awarded to Dr Fernández de la Cruz. The original article can be accessed on the JAMA Psychiatry website and cited as follows:

 Pérez-Vigil. A., Fernández de la Cruz, L., Brander, G., Isomura, K., Jangmo, A., Feldman, I., Hesselmark, E., Serlachius, E., Lázaro, L., Rück, C., Kuja-Halkola, R., D’Onofrio, B. M., Larsson, H., & Mataix-Cols, D. (2018). Evaluating the association of obsessive-compulsive disorder with objective indicators of educational attainment: A nationwide register-based sibling control study. JAMA Psychiatry, 75, 47-55.

The authors are with the Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.