OCD in children

[David Baxter PhD]

Does Your Child Have Obsessive-Compulsive Disorder?
October 18, 2004, KidsHealth.org

"What if I forget to bring my homework to school? Did I remember to feed my goldfish? I know I turned off the TV, but let me check to make sure."

All children have worries and doubts. But when your child can't stop thinking about them, they begin to hamper his ability to function. No matter how stressful the worries are, no matter how silly they may seem, and no matter how much your child wants them to go away, they do not subside on their own. In association with this anxiety, your child may begin to perform certain rituals, behaviors that are performed in a certain way over and over again. If these behaviors persist, your child may be diagnosed with obsessive-compulsive disorder (OCD).

It is reported that approximately 1 million children and adolescents in the United States suffer from OCD. This translates to one in 200 children. OCD is more prevalent than many other childhood disorders or illnesses, but it is often hidden because it causes pain and embarrassment to the child.

In the years when most children want to fit in with their peers, the discomfort and stress brought on by OCD can make them feel scared, out of control, and alone.

What can you do to help?

What Is OCD?
OCD is an anxiety disorder in which the brain gets stuck on a particular thought or urge and can't let go. OCD manifests itself in obsessive thinking or beliefs that tell a child: "If you don't do X, then something uncomfortable or even life-threatening will happen." (In younger children, compulsive behaviors may be evident without the "if...then" thinking.) The rise in anxiety or worry is so strong that the child must perform the task or dwell on the thought, over and over again, to the point where it interferes with everyday life. OCD can become extremely embarrassing and overwhelming for both the child and his family.

Experts aren't sure how OCD gets started, but it should never be viewed as the child's fault or something he can stop if he just tries harder. OCD is a disorder, just like a sleep disorder or dyslexia - it's not something the child can control. Experts do know that OCD tends to run in families, and just like in children, OCD in adults is often kept private so that most families are not aware of this disorder in their family histories.

OCD is best viewed as a "short circuit" in the brain's "worry computer," says John March, MD, author of OCD in Children and Adolescents: A Cognitive Behavioral Treatment Manual. This worry computer inappropriately and repeatedly cues the child to fear that something will happen. These cues are commonly called obsessions.

Obsessions are repeated thoughts or impulses that are out of place - they cause the child to experience anxiety or distress. They are out of the child's control, and they are different from normal thoughts. A child with these thoughts usually attempts to ignore or suppress obsessive thoughts or impulses by neutralizing them with another thought or action - a compulsion. For example, a child who is plagued with doubts about having turned off the stove might compulsively check the stove, again and again, to ensure that it is off.

Compulsions, or rituals, are the deliberate and repeated behaviors a child with OCD performs to relieve the anxiety caused by the obsessive thoughts. For example, a child who has a fear of germs may repeatedly wash his hands until the skin becomes raw; a child who has an obsession with neatness will redo her test paper so many times that she may tear a hole in it from constant erasing. Other times, compulsions might seem less clearly related to the obsessive thought.

Common OCD Behaviors in Children
OCD can make daily life difficult for children and families. The behaviors often take up a great deal of time and energy, making it more difficult to complete tasks such as homework or chores or enjoy life. In addition to feeling frustrated or guilty for not being able to control their own thoughts or actions, children with OCD also may suffer from low self-esteem because the disorder can lead to shame or embarrassment. Children often involve their parents in their rituals (for example, asking about a potential illness they think they have), leading to increases in family stress.

Children with OCD may feel pressured because they don't have enough time to do everything. They might become irritable because they have to stay awake late into the night or miss an activity or outing to complete their rituals. They might have difficulties with attention or concentration because of the intrusive thoughts.

In addition, obsessions and compulsions related to food are common. These can lead to abnormal eating habits (such as eating only one kind of food), thus compromising nutrition.

Studies of children and adolescents with OCD have revealed that the most common obsessions include:

• fear of dirt or germs
• fear of contamination
• a need for symmetry, order, and precision
• religious obsessions
• preoccupation with body wastes
• lucky and unlucky numbers
• sexual or aggressive thoughts
• fear of illness or harm coming to oneself or relatives
• preoccupation with household items
• intrusive sounds or words [/list:u] The following compulsions have been identified as the most common in children and adolescents:
  • grooming rituals, including hand washing, showering, and teeth brushing
  • repeating rituals, including going in and out of doorways, needing to move through spaces in a special way, checking to make sure that an appliance is off or a door is locked, and checking homework
  • rituals to undo contact with a "contaminated" person or object
  • touching rituals
  • rituals to prevent harming self or others
  • ordering or arranging objects
  • counting rituals
  • hoarding and collecting things
  • cleaning rituals related to the house or other items [/list:u] Signs of OCD
    Recognizing OCD in children is often difficult because they become adept at hiding the behaviors. It's not uncommon for a child to engage in ritualistic behavior for months, or even years, before parents know about it. Also, many children do not engage in their rituals at school, so parents may think that this is just a phase their child is going through.
    
    "Kids try to contain their thoughts or behaviors, and this creates anxiety," says David Sheslow, PhD, a pediatric psychologist. "Children experience embarrassment and sometimes feel like they are 'going crazy.' They try to keep it quiet and to blend it into the normal routine of their lives until they can't contain it anymore. This is when the parents become concerned. Even then, parents typically know of only some of their child's ritual thoughts and behaviors.
    
    "The child may ask the parent to join him in the ritualistic behavior: first the child has to do something and then the parent has to do something else. If a child says, 'I didn't touch something with germs, did I?' the parent might have to respond, 'No, you're OK,' and the ritual will begin again for a certain number of times," Dr. Sheslow explains. "Initially, the parents might not notice what is happening. Tantrums, overt signs of worry, and difficult behaviors are common when parents fail to participate in their child's rituals. It is often this behavior, as much as the OCD itself, that brings families into treatment."
    
    Parents can look for the following possible signs of OCD:
    • raw, chapped hands from constant washing
    • unusually high rate of soap or paper towel usage
    • high, unexplained utility bills
    • a sudden drop in test grades
    • unproductive hours spent doing homework
    • holes erased through test papers and homework
    • requests for family members to repeat strange phrases or keep answering the same question
    • a persistent fear of illness
    • a dramatic increase in laundry
    • an exceptionally long amount of time spent getting ready for bed
    • a continual fear that something terrible will happen to someone
    • constant checks of the health of family members
    • reluctance to leave the house at the same time as other family members [/list:u] Environmental and stress factors can signal the onset of OCD. These can include ordinary developmental transitions (such as starting school) as well as significant losses (such as the death of a loved one or moving).
      
      Diagnosing OCD
      In screening for OCD, your child's doctor or mental health professional will ask about obsessions and compulsions in language that your child will understand, such as the following questions:
      • Do you have worries, thoughts, images, feelings, or ideas that bother you?
      • Do you have to check things over and over again?
      • Do you have to wash your hands a lot, more than most kids?
      • Do you count to a certain number or do things a certain number of times?
      • Do you collect things that others might throw away (like hair or fingernail clippings)?
      • Do things have to be "just so"?
      • Are there things you have to do before you go to bed? [/list:u] Because it can be normal for children to answer yes to any of these questions, your child's doctor will also ask about your family's history of OCD, Tourette syndrome, and other motor or vocal tic disorders. OCD has a genetic component, which means that children whose family members have had any of these disorders may be more prone to OCD.
        
        Tic disorders often resemble OCD symptoms: approximately 35% to 50% of people with Tourette syndrome also have OCD (but only a small percentage of children with OCD also have Tourette syndrome).
        
        Disorders that frequently occur with OCD include other anxiety disorders, depression, disruptive behavior disorders (attention deficit hyperactivity disorder and oppositional defiant disorder), learning disorders, trichotillomania (compulsive hair pulling), and habit disorders such as nail biting or skin picking.
        
        Rarely, OCD symptoms or tics that come on very suddenly may be associated with a recent Group A streptococcus infection (strep throat or, less commonly, scarlet fever). This phenomenon is known as PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections). No one knows for sure why PANDAS occurs, but research is underway to learn more about it. One theory is that strep infections may trigger an antibody response in some children that causes changes in the brain, leading to symptoms of OCD. Presently there are no lab tests to diagnose PANDAS.
        
        Of course, just because your child has had strep throat doesn't mean he or she will also have PANDAS. Almost all school-age children have strep throat at some point, and the vast majority recover with no complications. Similarly, most children with OCD or tics do not have PANDAS. The condition may be considered only if a child's OCD symptoms or tics are directly preceded by, or significantly worsen after, a strep infection.
        
        Treating OCD
        The most successful treatments for children with OCD are behavioral therapy and medication. Cognitive-behavioral psychotherapy (CBT) helps children learn to change their thoughts and feelings by first changing their behavior. CBT involves exposure, or exposing the child to his fears to decrease his anxiety about it. For example, a child who is afraid of dirt might be exposed to something he considers dirty until he no longer fears it.
        
        For exposure to be successful, it is often combined with response prevention, in which the child's rituals or avoidance behaviors are blocked. For example, the child who fears dirt must not only stay in contact with the dirty object, he also must not be allowed to wash repeatedly. Some treatment plans involve having the child "bossing back" the OCD, giving it a nasty nickname, and visualizing it as something the child can control.
        
        Behavioral treatment with children works best when the whole family is involved, according to Dr. Sheslow. "Treating children from a behavioral perspective requires a high degree of cooperation," he says. "Without a considerable amount of family support, you won't have a high rate of success. Because cognitive behavioral treatments often provoke considerable anxiety, a good deal of support is needed. As well, it is important to find a therapist who knows about how to treat OCD. OCD can worsen if not treated in a consistent, logical, and supportive manner."
        
        Medication is often combined with CBT to get more complete and lasting results. Research shows that selective serotonin reuptake inhibitors (SSRIs) are most effective in children with OCD. These include medications such as fluoxetine, fluvoxamine, paroxetine, and sertaline. Another medication that may be prescribed is clomipramine. Most experts agree that medication should be used to treat children as a second choice to CBT. "Medication often can reduce the impulse to engage in ritualistic behavior. Therapy will help the child and family learn strategies to manage the waxing and waning of OCD symptoms," Dr. Sheslow says.
        
        "Many children can do well with CBT alone, others will need a combination of behavioral therapy and medication. It's important to use the treatments appropriately to avoid the long-term adverse effects of OCD on children's development," Dr. March says.
        
        How Can I Help My Child?
        Parents and children should understand that OCD is never the child's fault. Once a child is in treatment, parents are encouraged to participate, to learn more about OCD, and modify their expectations and be supportive. You need to realize that kids get better at different rates and day-to-day comparisons of your child's behaviors should be avoided. Small improvements should be recognized and praised.
        
        "It is rare to find a child with OCD without finding a family with OCD," Dr. Sheslow says.
        
        Your entire family should be educated and supportive at all times. The more personal criticism can be avoided, the better. Members of your family should keep in mind that it's the OCD that is causing the problem, not the child. Family routines should be kept as normal as possible, family members should learn strategies to approach members with OCD, and if your child is on medication, the regime should never waver.
        
        It's not surprising that many people keep this disorder hidden". This is not something that people want to advertise; there's an embarrassment about it," says Dr. Sheslow, who explains that OCD is different from other disorders, such as a fear of dogs, for example. Other disorders are easier for people to talk about than OCD.