Hoarding Disorder (HD)

What is Hoarding Disorder (HD)?

Hoarding Disorder is new to the most recent edition of the clinician’s diagnostic manual (DSM-5), with hoarding previously categorized as a subtype of obsessive-compulsive disorder (OCD). Although approximately 30% of individuals with OCD report collecting and saving obsessions and hoarding behaviors1, less than 20% of people with HD have OCD2.

While there is increasing research in understanding hoarding behaviours in youth, much of the data is based upon adult reporting. As a result, information outlined in this section borrows heavily from the adult literature.

Hoarding disorder is associated with three key features:

  1. Ongoing and significant difficulty getting rid of possessions (i.e. throwing away, recycling, selling, etc.), regardless of their value; and strong urges to save and/or acquire new, often non-essential, items, that if prevented leads to extreme distress. Non-essential includes items that are both useless (i.e. broken), as well as those with limited value (e.g. 10 skirts in every color but never worn)
  2. Living space is severely cluttered, preventing it from being used for its intended purpose.
  3. Significant impairment in social, occupational, and other important areas of functioning as evidenced by:
  • Impaired physical health
  • Missed school or work, and compromised academic potential
  • Social isolation
  • Emotional distress
  • Family stress and impaired parent-child relationship

Two additional specifications include:

  1. Whether the youth is also engaged in excessive acquisition (It is currently estimated that upwards of 80-90% of individuals with hoarding also experience excessive acquisition of items through collecting, buying, and even theft.), and,
  2. Whether the youth has any insight or awareness that their behaviour is problematic.

Facts

  • Hoarding occurs in 2-6% of children and adults during their lifetime, with the average age of onset in late childhood and early adolescence
  • There are no gender differences (There does not appear to be a gender difference in the prevalence of HD but there does appear to be differences with co-occurring problems
  • Hoarding runs in families
  • Approximately 50% of the time onset is preceded by a chronic or acute stressful or traumatic life event
  • In individuals with HD approximately 70% also have MDD; 25% have GAD, about 30% have social anxiety or ADHD-inattentive type; and 20% have OCD

Distinguishing consumerism and collecting, from HD

Many cultures worldwide place some emphasis on consumerism, and this often begins early in childhood. Children quickly learn to exhibit preferences for particular items, and can tell you what the current trends are and why it matters to own the latest X. They often delight and gain comfort in having collections of various sorts. During the preschool years this helps children learn about categorization, belonging, and other important concepts. As they mature, collections assist with developmental skills such as organization and problem solving, as well as providing a sense of control and mastery over their own possessions. It is also common for children to develop emotional attachments to items and to struggle to part with items once these are no longer needed. However, in youth with HD all of these factors are magnified. These youth struggle to self regulate, failing to recognize that the number of items or degree of their behaviour is problematic. They lack the ability to sort through items that are useful versus useless, or to predict what will and will not be needed into the future. They engage in extreme behavioural outbursts if asked to discard an item, or if prevented from acquiring a desired object. This is not one small tantrum, but many huge explosions, every time a limit is set. The child’s bedroom may look like the inside of a chaotic bazar, with drawers, closets, and other space crammed full. And if this were not the case, it would be if not for the ongoing decluttering intervention of an adult.  Collecting and having the desire to have items runs on a continuum, and in moderate amounts it can be typical of the culture and time of life (e.g., wanting what other kids have so s/he can fit in). However, it is the number and amount of acquiring, and the negative impact on functioning that is a defining feature of HD.

Note: To learn about additional features often present in Hoarding Disorder, click here.

SIGNS & SYMPTOMS

Thoughts & Beliefs (Note: very young children may be unable to identify specific thoughts):

  • It might be important or useful next year
  • It makes me feel safe and secure
  • Dad said I must not be wasteful
  • Its my responsibility to ensure its used as no-one else in my family will use it
  • I cannot make mistakes
  • I’m really attached to it. Its part of who I am.

Physical feelings:

  • Internal urges or a sense of being driven or propelled forward
  • Muscle tension
  • Exhaustion and fatigue
  • Attachment to possessions
  • Thrilling sensations

Emotions:

  • Anxiety/worry/fear
  • Loss and grief
  • Confusion
  • Excitement and anticipation
  • Pleasure and relief
  • Shame and guilt
  • Frustration and anger

Behaviors:

  • Saving and/or acquiring functional and non-functional items. These can include:
    • Used paper towels, tissues, etc.
    • Empty bottles or containers
    • Candy wrappers
    • Old magazines
    • Old or broken toys
    • Old, unimportant school papers
    • Rocks, leaves, and other nature items
  • Searching for old items misplaced in the home due to clutter and disorganization
  • Difficulty discarding
  • Poor concentration and inattentiveness
  • Difficulty with decision making

COMMON SITUATIONS OR AFFECTED AREAS

  • Missed school
  • Cluttered living conditions especially in the bedroom
  • Poor organization and focus
  • Impaired relationships
  • Social isolation
  • Family conflict

How Hoarding impacts the child throughout childhood and adolescence

Saving and collecting is a common pastime for most youth that assists in personality and identify formation.  Items range from dolls, cars, and trading cards, to pencils and stickers in early childhood, to music, clothing, and electronics in adolescence. Despite similar interests in youth who do and do not hoard, children who hoard are distinct due to their extreme focused interest around the items, including excessive discussion, or seeking ongoing reassurance, about the items, significant distress discarding the items, and the amount of accumulated clutter relating to these items. Like adults, youth who hoard often lack awareness that their behaviours are problematic or unusual. However, since children live with others, parents and guardians play a significant role in controlling the degree of items and related clutter, often restricting what the youth is allowed to purchase to the bedroom, removing items from the home when the youth is at school or sleeping, and avoiding locations associated with item acquisition (e.g. specific stores). Yet as the child matures, urges to acquire strengthen and families often find themselves struggling to set and maintain limits. Not surprisingly parents and guardians will, at times, accommodate or give in to their child’s incessant demands to avoid a public tantrum or to gain some peace and quiet. Unfortunately these intermittent “wins” for the child only serve to strengthen the child’s hoarding behaviours. Furthermore, as children mature, access to disposable income and independence increases, and thus so too does the capacity to acquire more items. Overtime, youth who hoard may encounter peer rejection and social isolation as their peers view the hoarding as “weird” and/or as hoarding takes over as a pastime, alienating the youth from other normative activities including social, academic, and occupational pursuits.

 

Cite:

  1. Rasmussen & Eisen, 1992; Samuels et al., 2002
  2. Frost, Steketee, & Tolin, 2011
Suzanne's Story

Suzanne is in grade five and is known fondly as “little girl, big heart.” Suzanne has a huge capacity for love and kindness; however, Suzanne’s parents have started to wonder whether her capacity for empathy and attachment might be problematic. They recall Suzanne always has shown a strong attachment to her possessions, becoming highly upset if things got lost or broken. This was manageable initially, but as Suzanne’s belongings grew and she resisted getting rid of things, so too did the disorganization.  Her room is now packed, from toys she has outgrown and small knick-knacks from party goodie bags, to empty candy and toy boxes and cast offs her friends have given her. When her parents insist she not bring home materials from art class or that she recycle old worksheets from school, she becomes highly distressed, crying and screaming. Her most recent episode resulted in her kicking her mother, something she has never done before. Furthermore, her parents have discovered that Suzanne has been stashing empty bottles and containers under her bed, obtained from the recycling bins at school. They are at a loss as to how to help Suzanne, and it seems for every one item they “sneak out,” there always seem to five more waiting in the wings.