What is Obsessive-Compulsive Disorder?

Obsessive-compulsive disorder, or OCD, is a medical disorder that causes repetitive, unpleasant thoughts (obsessions) or behaviors (compulsions) that are difficult to control. Unlike ordinary worries or habits, these obsessions and compulsions may consume significant amounts of time (more than an hour per day), may interfere with a person's daily schedule, and may cause significant distress. OCD affects approximately one percent of children and adolescents. The tendency to develop this disorder involves complex genetic and environmental factors.

Examples of obsessions include recurrent concern about germ contamination, persistent worry that a family member may become sick, or excessive preoccupation with perfection or tidiness. Compulsions, also known as rituals, include repetitive behaviors (such as washing hands, checking locks) and repetitive thoughts (such as silently counting, praying, or repeating words) that the person feels must be completed. A person who has compulsions believes that performing these rituals will prevent a frightening event (for example, "If I count to three every time I talk to my mother, then she won't die").

People with obsessive-compulsive disorder may try to ignore these thoughts or avoid the behaviors but are generally unable able to do so. Whereas adults with OCD may recognize that their obsessions or compulsions are not rational, a child or adolescent may not have that awareness. top

What Does Obsessive-Compulsive Disorder Look Like in Children and Adolescents?

The thoughts and behaviors associated with obsessive-compulsive disorder are often perplexing to parents, teachers and peers. Recognizing the symptoms of obsessive-compulsive disorder may be challenging, as the symptoms can easily be misinterpreted as willful disregard, oppositionality, or meaningless worry. In addition, children and adolescents may try to hide their symptoms or may not know how to express their underlying worries. Often, a parent or teacher only sees the end result of the symptom (hours in the bathroom, extended time alone in the bedroom, or tantrums when the child cannot do something his or her way).

Symptoms may vary over time and may change in the way they appear, which can further complicate diagnosis. Children may be able to resist the obsessions and compulsions at school but not at home. The symptoms may fluctuate, with more symptoms at stressful periods and fewer symptoms at other times. Other medical conditions can mimic the disorder, and other conditions may co-occur with the disorder.

If left untreated, the condition may lead to considerable worry or limitations in other areas of the child's life. Peer relationships, school functioning, and family functioning all may suffer. Depression may develop. In some situations, in response to the extreme anxiety, social isolation, and limited activities, a child may develop thoughts of self-harm or not wanting to be alive. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis. top

 ► At Home

Symptoms of obsessive-compulsive disorder at home are often more intrusive than at school. Life for the child and the family can become very stressful, and all family members including the child may feel powerless to change rigid patterns of behavior.

At home, children with OCD may have a combination of the symptoms listed below.

• Repeated obsessional thoughts that they find unpleasant. Unlike ordinary worries, these obsessions (such as fear of becoming fatally ill) are not generally realistic. Often the child may deny these thoughts or behaviors, or be embarrassed by them.
• Repeated actions to prevent a feared consequence (such as hand washing to avoid germ contamination, excessive tidying to prevent extreme discomfort or fatal consequence)
• Consuming obsessions and compulsions. The child or adolescent is continually preoccupied with these worries (for example, a child avoids nearly all contact with objects due to fear of contamination, or an adolescent bathes and washes hands for hours each day).
• Extreme distress if others interrupt a ritual. Children may have extended tantrums if a parent insists that the child move on to the next task.
• Difficulty explaining unusual behavior. Children with OCD may not be able to explain what their worries are or why they feel compelled to repeat their behaviors.
• Attempts to hide obsessions or compulsions. Children and adolescents are often ashamed of their worries or habits and will make great efforts to keep their thoughts or rituals a secret.
• Resistance to stopping the obsessions or compulsions (for example, parental reassurance that the child will not become ill from touching an item does not reassure the child). Frequently, children cannot ignore their symptoms and, instead, feel they must continue their rituals.
• Concern that they are "crazy" because of their thoughts. Children with OCD may recognize that they think differently than others their age. Consequently, these children often have low self-esteem. top

 ► At School

The differences in behaviors seen at home and at school can be significant. At school, students may be successful in suppressing symptoms, while they may be unable to do so at home. Families often seek treatment once symptoms affect school performance.

At school, a child with OCD may have a combination of the symptoms listed below.

• Difficulty concentrating, which may affect many aspects of school activities, from following directions and completing assignments to paying attention in class. Concentration can be affected by persistent, repetitive thoughts that are not known to others. Finishing work in the appropriate time can be difficult, and just starting schoolwork can be difficult, too.
• Social isolation or withdrawal from interactions with peers
• Low self-esteem in social and academic activities
• Problem behaviors, such as fights or arguments, resulting from misunderstandings between the child and peers or staff. Unusual behaviors may be distressing to the child or peers and lead to clashes.
• Medication side effects that can interfere with school performance. Once a child is receiving medication treatment for OCD, the child should be monitored carefully for new mood changes or behaviors, which could potentially reflect medication side effects.
• Other conditions, such as Attention Deficit/Hyperactivity Disorder (ADHD), which also may be present, compounding any learning challenges. Having one mental health condition does not "inoculate" the child from having other conditions as well.
• Learning disorders and cognitive problems, which are often overlooked in this population. A child's difficulties or frustrations in school should not be presumed to be due entirely to the OCD. If the child still has academic difficulty after OCD symptoms are treated, an educational evaluation for learning disabilities should be considered. A child's repeated reluctance to attend school may be an indicator of an undiagnosed learning disability. top

 ► At the Doctor's Office

A child's obsessive-compulsive symptoms often are not seen during an office visit. Clinicians may benefit from talking with parents, school staff, and other important caregivers to evaluate a child's functioning in each area to determine the underlying cause of the child's symptoms.

Clinicians may face some of the following challenges in diagnosing and treating a child or adolescent with OCD.

• Because of the variability of symptoms and their changing appearance as a child grows, a clinician may need to see a child over time to determine the appropriate diagnosis
• Other conditions may look like, or may accompany, obsessive-compulsive disorder. These conditions include eating disorders (excessive focus on food habits and weight), phobias (excessive worry regarding a specific object or situation, such as spiders or flying), and psychotic disorders (preoccupation with unusual beliefs or fears).
• Additional conditions often seen with obsessive-compulsive disorder should be considered. These include Tourette's disorder (a condition of repetitive, distressing motor and vocal tics), Attention Deficit/Hyperactivity Disorder (ADHD), depression, social phobia, and panic disorder.
• Researchers have identified a possible link between strep throat infections and the sudden onset of OCD symptoms in a very small number of children. The condition is known as PANDAS, an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. The children usually have dramatic, "overnight" onset of symptoms, including motor or vocal tics, obsessions, and/or compulsions. Although this syndrome is a rare occurrence, it makes sense for families to discuss any recent illnesses with their child's clinician.
• Young people are often ashamed and embarrassed about their OCD symptoms and may not volunteer information. Phrasing questions with particular sensitivity and compassion may allow a more complete picture of symptoms to emerge, especially since obsessions or compulsions might involve distasteful thoughts or worries of a sexual nature.
• Children may be unaware, or unwilling to admit, that their behavior may indicate symptoms of a disorder
• Families may need to be coached about what they can reasonably expect from their child. Children who suffer from OCD will benefit if their family understands that therapy and medicines may reduce, but do not cure, symptoms. top

How Is Obsessive-Compulsive Disorder Treated?

Obsessive-compulsive disorder is treatable through ongoing interventions provided by a child's medical practitioners, therapists, school staff, and family. These treatments include psychological interventions (counseling), biological interventions (medicines), and accommodations at home and school that reduce sources of stress for the child. Open, collaborative communication between a child's family, school, and clinicians optimizes the care and quality of life for the child with obsessive-compulsive disorder. top

 ► Psychological Interventions (Counseling)

Counseling can help children with OCD, and everyone around them, to understand that OCD symptoms are caused by an illness with complex genetic and environmental origins--not by flawed attitude or personality. Counseling also can reduce the impact of symptoms on daily life. A variety of psychological interventions can be helpful, and parents should discuss their child's particular needs with their clinician to determine which psychological treatments could be most beneficial for their child.

• Cognitive Behavior Therapy (CBT) is usually recommended for children and adolescents with obsessive-compulsive disorder. In CBT, a young person is helped to become aware of problem behaviors or thoughts in particular situations and is then guided by the clinician to try alternative behaviors for those situations. With younger patients, personifying the obsessions (for example,"Germy" to describe the fear of germs) allows children to "fight back" against the thoughts or behaviors that could keep them away from peers or family activities. Cognitive behavior therapy focuses on changing behaviors and on developing more positive thinking patterns as alternatives to the negative thoughts that cause symptoms.
• CBT and related treatments, such as exposure response prevention and behavior therapy, are based on well-researched methods that have successfully helped children and adolescents to increase healthy behaviors and thoughts. These therapy approaches can enable people with OCD to tolerate their worries, without having to perform their rituals. Young people may benefit from behavior therapy or CBT on an ongoing basis.
• Individual psychotherapy may be useful for young people with OCD, particularly when they have ongoing stressors in their lives that make symptoms worse. Children with obsessive-compulsive disorder often carry a sense of failure, as if the illness was their fault. In many cases, they know that their disturbing thoughts and rituals are generated by their own mind, which can increase their sense of self-blame. Individual psychotherapy can help young people become aware of and address their feelings of failure and self-blame.
• Parent guidance sessions can help parents to manage their child's illness, identify effective parenting skills, learn how to function as a family despite the illness, and to address complex feelings that can arise when raising a child who has a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.
• Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting.
• School-based counseling can be effective in helping a child with OCD navigate the social, behavioral, and academic demands of the school setting. top

 ► Biological Interventions (Medicines)

While psychotherapy may be sufficient to treat some children with OCD, other children's symptoms do not improve significantly with psychotherapy alone. These children may benefit from medications.

The U.S. Food and Drug Administration (FDA) has approved Anafranil, Luvox, Prozac (fluoxetine), and Zoloft for treating children and adolescents with OCD. Medications approved by the FDA for other uses and age groups are also prescribed for young people with OCD. The FDA allows doctors to use their best judgment to prescribe medication for conditions for which the medication has not specifically been approved.

The antidepressants Celexa, Lexapro, and Paxil, are also commonly prescribed to treat symptoms of OCD. These medications, along with Luvox, Prozac, and Zoloft, belong to a group of medications called Selective Serotonin Reuptake Inhibitors, or SSRI’s. Ananfranil, another type of antidepressant medication, has anti-obsessional properties.

Sometimes larger doses of antidepressants (up to 4 times the standard antidepressant dose) are prescribed to improve OCD symptoms. If OCD symptoms occur in children with autism spectrum disorders, sometimes very low doses (for example, 1 mg of Prozac) are prescribed.

In most cases these medicines begin to be effective in reducing symptoms after the child or adolescent has taken them for at least 2-4 weeks. Fully 12 weeks may be required in order to determine whether the medication is going to be effective for a particular individual. Medications should only be started, stopped, or adjusted under the direct supervision of a trained clinician.

There is no "best" medicine to treat OCD, and it is important to remember that medicines usually reduce rather than eliminate symptoms. Different medicines or dosages may be needed at different times in a child's life or to address the emergence of particular symptoms. Successful treatment requires taking medicine daily as prescribed, allowing time for the medicine to work, and monitoring for both effectiveness and side effects. The family, clinician and school should maintain frequent communication to ensure that medications are working as intended and to monitor and manage side effects.

The following cautions should be observed when any child or adolescent is treated with antidepressants.

• Benefits and risks should be evaluated. Questions have arisen about whether antidepressants can cause some children or adolescents to have suicidal thoughts. The evidence to date shows that antidepressants, when carefully monitored, have safely helped many children and adolescents. The latest reports on this issue from the U.S. Food and Drug Administration can be found on its web site at www.fda.gov. Consideration of any medicine deserves a discussion with the prescribing clinician about its risks and benefits.
• Careful monitoring is recommended for any child receiving medication. Though most side effects occur soon after starting a medicine, adverse reactions can occur months after medicines are introduced. Agitation, restlessness, increased irritability, or comments about self-harm should be addressed immediately with the clinician if any of these symptoms emerge after the child starts an antidepressant. Frequent follow-up (weekly for the first month) is now advocated by the FDA for children starting an antidepressant.
• Some children who have OCD may also have bipolar disorder. In some individuals with bipolar disorder, antidepressants may initially improve depressive symptoms but can sometimes worsen manic symptoms. While antidepressants do not "cause" bipolar disorder, they can unmask or worsen manic symptoms.

Helpful information about specific medications can be found at www.medlineplus.gov (click on "Drug Information") and in the book Straight Talk About Psychiatric Medications for Kids (Revised Edition) by Timothy E. Wilens, MD. top

 ► Interventions at Home

At home, as well as at school, providing a sympathetic and tolerant environment and making some adaptations may be helpful to aid a child or adolescent with OCD.

• Understand the illness. Understanding the nature of obsessive-compulsive disorder and its consequences will help parents sympathize with a child's struggles.
• Listen to the child's feelings. Isolation can foster depression in these children. The simple experience of being listened to empathically, without receiving advice, may have a powerful and helpful effect. Parents should not let their own worries prevent them from being a strong source of support for their child.
• Plan for transitions. Getting to school in the morning or preparing for bed in the evening may be complicated by the urge to complete rituals. Anticipating and planning for these transition times may be helpful for family members.
• Adjust expectations until symptoms improve. Helping a child make more attainable goals when symptoms are more severe is important, so that the child can have the positive experience of success.
• Praise the child's efforts to resist symptoms. Children often feel like they only hear about their mistakes. Even if improvements are small, every good effort deserves to be praised.
• Talk as a family about what to say to people outside of the family. Determine what feels comfortable for the child (for example, "I have this thing called OCD. I'm getting help for it, which is making things easier for me. I might do funny things sometimes, but we can still play together"). Even if the decision is made not to discuss this medical condition with others, having an agreed-on plan will make it easier to handle unexpected questions and minimize family conflicts.
• Understand parental limits. Fulfilling a child's extreme wishes related to symptoms (for example, showering for hours) may be neither possible nor advisable. Such well-intended efforts to support a child may actually delay the development of new coping strategies and reduce the benefits of behavior therapy. Finding the balance between supportive flexibility and appropriate limit setting is frequently challenging for parents and may be aided by the guidance of a trained professional.
• "It's the OCD talking." Taking a supportive stance in which parents, child and clinicians unite together to fight symptoms is an effective strategy to distinguish between symptoms, which are frustrating, and the child, who is doing the best he or she possibly can. Sometimes it is useful to help the child distinguish himself or herself from the illness ("It's the OCD talking"). top

 ► Interventions at School

There are many ways that schools can help a child with obsessive-compulsive disorder succeed in the classroom. Meetings between parents and school staff, such as teachers, guidance counselors, or nurses, will allow for collaboration to develop helpful school structure for the child. The child may need particular changes (accommodations/modifications) within a classroom.

Examples of some accommodations, modifications, and school strategies include the following:

• Check in on arrival to see if the child can succeed in certain classes that day
• Allow more time to complete certain types of assignments
• Accommodate late arrival due to symptoms at home
• Identify ways for teachers to assist the child in breaking out of an obsession or compulsion
• Offer strategies for the child to resist uncomfortable thoughts
• Allow the child to tape record homework if the child cannot touch writing materials
• Give the child a choice of projects if the child has difficulty beginning a task
• Suggest that the child change the sequence of homework problems or projects ( for example, if the child has fears related to odd-numbers, start with even-numbered problems )
• Adjust the homework load to prevent the child from becoming overwhelmed. Academic stressors, along with other stresses, aggravate symptoms.
• Anticipate issues such as school avoidance if there are unresolved social and/or academic problems
• If the child insists on certain OCD rituals at school, work with the child to identify less intrusive rituals (such as tapping one desk rather than tapping every desk)
• Assist with peer interactions in order to alleviate concerns for both the child and peers
• Be aware that transitions may be particularly difficult for the child. Negotiate reasonable expectations for transitions within school hours. When a child with obsessive-compulsive disorder refuses to follow directions or to transition to the next task, for example, the reason may be anxiety rather than intentional oppositionality.
• Support and reinforce behavioral strategies developed by the clinician. This should be discussed with the child's parents and behavior therapist. Please refer to "Psychological Interventions" above, for details regarding behavior therapy.
• Encourage the child to help develop interventions. Enlisting the child in the task will lead to more successful strategies and will foster the child's ability to problem-solve.
• Please click on School-Based Interventions for a more complete list of school accommodations for children with OCD

Flexibility and a supportive environment are essential for a student with obsessive-compulsive disorder to achieve success in school. School faculty and parents together may be able to identify difficult situations and develop remedies to reduce a child's challenges at these times. top

Helpful Resources

Many online resources and books are available to help parents, clinicians, and educators learn more about children and adolescents with obsessive-compulsive disorder. Click here for a wide selection of resources. top

Sources

Information provided above on obsessive-compulsive disorder drew from sources including:

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Association, 1994

Bostic, JQ, Bagnell, A. School Consultation. In Kaplan BJ, Sadock VA. Comprehensive Textbook of Psychiatry, 8th edition. Philadelphia: Lippincott Williams and Wilkins (in press)

Dulcan, MK, Martini DR. Concise Guide to Child and Adolescent Psychiatry, 2nd Edition. Washington, DC: American Psychiatric Association, 1999

Lewis, Melvin (ed.) Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd Edition. Philadelphia: Lippincott Williams and Wilkins, 2002

Obsessive-Compulsive Foundation, OCD in Children. Internet location: www.ocfoundation.org/ocf1040a.htm September 17, 2004 top