OCD in Kids

(The following is an abridged excerpt from "The OCD Workbook - Your Guide to Breaking Free from OCD" by Bruce M. Hyman, Ph.D. and Cherry Pedrick, RN. , and "Detecting Obsessive-Compulsive Disorder in Children and Teens," by Cherry Pedrick, RN in Teachers in Focus, February 1999. Modifications in the text were made for clarity and brevity. To learn more about  "The OCD Workbook" and order a copy, click here)

About 1 percent of children, that is, some 200,000 American children and teenagers – have OCD. In childhood OCD, a family history of OCD is more frequent than in adult onset OCD, leading us to believe that genetic factors may play more of a role in childhood OCD.

Months or years may pass before parents become aware that their child has a problem because children often hide their obsessions and compulsive behaviors. They try to suppress symptoms until they are alone, or at least until they get home from school. Children have a very strong need to feel accepted by others, to fit into their peer group. The strange behaviors and senseless compulsions are embarrassing to them – so they hide them.

It is best to treat OCD early. The longer it goes untreated, the more generalized the symptoms become. They invade more and more of the child's life and make OCD more difficult to treat . With treatment, OCD may or may not follow the child into adulthood. Some children may have minimal symptoms as adults – or no symptoms at all. Others go into remission – their symptoms disappear, but return during adulthood. OCD often changes over time. Symptoms experienced as an adult may be different from those experienced as a child. Why do symptoms sometimes disappear with treatment, and then reappear later in life? No one knows for sure, but hormones and stress may cause changes in a person's biological makeup, and thus affect the expression of OCD symptoms.

At some point during the course of the disorder, adults with OCD recognize that their obsessions and compulsions are excessive or unreasonable. This requirement for diagnosis does not apply to children. They may lack adequate cognitive awareness to make this judgment. When they are anxious and obsessing, even adults with OCD may not realize they are being unreasonable.

Most children go through developmental stages characterized by compulsive behaviors and rituals that are quite normal. These behaviors are common between the ages of two and eight, and seem to be a response to children’s needs to control their environment and master childhood fears and anxieties. Dr. Henrietta Leonard, who studied the relationship between children's developmental rituals, superstitions, and OCD, wrote that between the ages of four and eight the developmental rituals are usually most intense. Boys express their belief that girls have "cooties," a form of imagined contamination where boys may vehemently avoid being touched by girls. By age seven collecting things (hoarding in OCD) becomes common. sports cards, comic books, toy figures, jewelry and dolls are among the popular collectibles. Between the ages of seven and eleven children's play becomes highly ritualized and rule-bound. Breaking the rules of a game is likely to be met with cries of "No fair!" In adolescence rituals may subside but obsessive preoccupation with an activity or a music or sports idol is common.

Superstitions are ritual-like behaviors often seen in normal children. These are forms of "magical thinking" in which children believe in the power of their thoughts or actions to control events in the world. "Lucky" numbers and rhymes, such as "step on a crack, break your Momma’s back," helps to bring about a sense of control and mastery. These normal childhood rituals advance development, enhance socialization, and help children deal with separation anxiety. Young children's’ rituals help them develop new abilities and define their environment. As they mature and develop into adulthood, most of these ritualistic behaviors disappear on their own. In contrast, rituals of the child with OCD persist well into adulthood. They are painful, disabling, and result in feelings of shame and isolation. Attempts to stop doing the rituals result in extreme anxiety.

Parents of a child with OCD are frequently frightened, confused, and frustrated by their child's persistence and preoccupation with cleanliness, orderliness, or checking rituals. Often, parents react at the extremes of either intimidation or passive enabling. If parents overreact and attempt to interrupt the behaviors, the child may become hostile and extremely anxious. If parents give in to the rituals, the child never learns to confront his or her fears. Out of frustration, many parents give in to the child and may even reluctantly assist in the rituals, for example, doing repeated loads of the child's laundry because he insists his clothes are "contaminated."

Obsessions that focus on contamination are the most commonly reported obsessions in children. Fears of contamination by dirt and germs lead to avoidance of suspected contaminates and excessive washing. They may wash in a self-prescribed manner, more frequently, or for excessive lengths of time.

An obsession with contamination sometimes produces the opposite effect. In these cases, fear of contamination of body parts, personal objects, or both, leads to a reluctance or outright refusal to touch them. Observe for untied shoes, un-brushed teeth, sloppy clothing, and uncombed, dirty hair – especially in a child known previously to be neat and well-groomed.

Checking compulsions are also common in children and adolescents with OCD. They are often precipitated by fear of harm to self or others, or the child may be troubled by extreme doubt. Checking such things as doors, light switches, windows, electrical outlets, and appliances may take up hours every day. The child may spend hours on an assignment that should take only an hour or feel compelled to check and recheck answers on assignments – to the point that it interferes with the completion of homework.

Some children with OCD have obsessions with numbers. They may have "safe" and "unsafe" numbers, repeat actions a certain number of times, or repeatedly count to a given number. Children may also repeat actions, such as walking through a doorway, until it "feels right" or in a self-prescribed manner. Look for repetitious questioning, reading sentences over and over, and numerous eraser marks on papers from erasing and rewriting words or numbers.

Symmetry rituals may be manifested by tying and retying shoes or constantly rearranging objects until they are even. Items must be arranged in such a way that they appear symmetrical to the child. Many children with OCD have difficulty wearing certain clothes. Hypersensitivities to touch, taste, smell, and sound are common.

Fear of harming others or self, excessive moralization, and religiosity are often seen in children with OCD. Children and teenagers with OCD frequently have a tendency toward perfectionism and rigidity or stubbornness. They are likely to have above normal intelligence, have a more adult-like moral code, have more anger and guilt, be disruptive, and have a more active fantasy life.

Below is a list of signs of OCD in children to look for. Keep in mind when reading them that, by definition, OCD symptoms must be time consuming, cause marked distress, or significantly interfere with one's life. These are simply signs that there may be a

problem. If you notice them, discuss them with your child in a nonthreatening way. If OCD is suspected, consult a psychiatrist that specializes in treating OCD.

Signs of Obsessive-Compulsive Disorder in Children (Adapted and expanded from Detecting Obsessive-Compulsive Disorder in Children and Teens, by Cherlene Pedrick RN in Teachers in Focus, February 1999)

• Being overly concerned with dirt and germs.
• Frequent hand washing or grooming, often in a ritualistic manner – red, chapped hands from excessive washing.
• Long and frequent trips to the bathroom.
• Avoiding playgrounds and messy art projects, especially stickiness.
• Untied shoes, since they may be "contaminated."
• Avoiding touching certain "unclean" things.
• Excessive concern with bodily wastes or secretions.
•  Insistence on having things in a certain order.
•  Having to count or repeat things a certain number of times, having "safe"  or "bad" numbers.
• Repeating rituals, such as going in and out of doors a certain way, getting in and out of chairs in a certain way, or touching certain things a fixed number of times. This may be disguised as forgetfulness or boredom.
• Excessive checking of such things as doors, lights, locks, windows, and homework.
• Taking excessive time to perform tasks. You may find a lot of eraser marks on school work.
• Going over and over letters and numbers with pencil or pen.
• Excessive fear of harm to self or others, especially parents.
• Fear of doing wrong or having done wrong.
• Excessive hoarding or collecting.
• Staying home from school to complete assignments, checking work over and over.
• Withdrawal from usual activities and friends
• Excessive anxiety and irritability if usual routines are interrupted.
• Daydreaming – the child may be obsessing.
• Inattentiveness, inability to concentrate or focus (often mistaken as ADD).
• Getting easily, even violently upset over minor, trivial issues.
• Repetitive behaviors including aimlessly walking back and forth in the halls.
• Unexplained absences from school.
• Persistent lateness to school and for appointments.
• Excessive, repetitive need for reassurance for having done, thought, or said something objectionable.
• Asking for reassurance, when the answer has already been given.
• Rereading and re-writing, repetitively erasing.

Adults usually seek treatment because OCD is interfering with their lives. Children don't always recognize that they have a problem. They are often brought to the doctor when they exhibit unacceptable behavior and difficulty in school. Young people and their parents need to know there is hope and help for children with OCD.

As with adults, the combined use of medication and cognitive-behavior therapy is widely recognized as the best treatment for childhood OCD (March, 1998). Discuss your options with your child’s medical team. You may want to try CBT alone first, or combine CBT with medication. In severe cases, you will probably want to start medication before beginning CBT. Together, CBT and medication are powerful tools in the struggle against OCD.

First, let’s summarize medication treatment for children. A detailed discussion of medication treatment of obsessive-compulsive disorder is beyond the scope of this book. This is only a review.

As with adults, five medications make up the first line of defense in medication therapy for children with OCD: Anafranil, Prozac, Zoloft, Paxil, Luvox, and Celexa. It takes up to 12 weeks at the proper dose to determine if a medication is going to work. If one medication doesn’t work, there is a good chance that another will. It is necessary for the child to make an attempt at resisting OCD symptoms while the medication is being tried. This is where cognitive-behavior therapy can be very helpful by training the child in the techniques of confronting obsessive worries and resisting compulsions.

Children can benefit greatly from cognitive-behavior therapy (CBT) for OCD using exposure and ritual prevention. Developed in the 1960's this "action-oriented" approach to treatment helps children confront their OCD fears and learn new, more appropriate responses to fear provoking situations, rather than doing rituals. For example, a child who fears contamination by dirt or germs learns would be asked to touch an feared object bit by bit until the child learns that the object is not harmful or dangerous. At the same time, the therapist works with the child to limit or even stop the compulsive handwashing and excessive showering behaviors. Wherever the fears and avoidances occur in real live, the CBT therapist assists the child to face those very situations. Eventually, through practice and persistence, the child learns to tolerate increasing degrees of "contamination" without having to resort to compulsive behaviors. To conduct CBT properly requires a high degree of therapist training and skill in gearing the treatment for the individual child's OCD problem.

Keys to Helping Children with OCD       

Childhood onset OCD has been linked to group A beta hemolytic streptococci (GABHS), the bacteria behind strep throat. It is thought that the body forms antineuronal antibodies against the bacteria. These antibodies interact with basal ganglia neural tissue. This leads to OCD symptoms or intensifying of existing symptoms. For more in-depth information on PANDAS by Dr. Marc Reitman, please click here.

Children whose OCD is the result of this relatively rare autoimmune reaction of the body have significant improvement or elimination of OCD symptoms when the strep infection is treated with antibiotics (March, 1998). It is important to get prompt treatment for strep infections. A sudden onset or worsening of OCD symptoms accompanied by upper respiratory distress warrants a trip to the doctor to check for signs of strep infection.

Children and teenagers with OCD often have one or more other disorders. Tourette Syndrome, tic disorders, ADHD, learning disorders, disruptive disorders, depression, and other anxiety disorders are the most frequently seen disorders in children and teens with OCD. Depression tends to begin after OCD has made its home. Possibly, it is in response to the OCD (Piacentini, 1997; March, 1998).

When children have one or more other disorders, it is important to coordinate cognitive-behavior therapy for OCD with the treatments for the other disorders. Doctors, therapists, teachers, counselors, and parents need to work as a team with the child to gain the upper hand over OCD and its team of disorders.

Tourette Syndrome (TS) is an inherited, neurological disorder that affects about 200,000 people in the US (Koplewicz, 1996). It is characterized by repeated and involuntary body movements and vocal sounds. These are called tics. Symptoms begin before age 21 and last at least one year. Boys are three to five times more likely to have TS. It occurs in only one out of every two thousand children, but as many as 15 percent of children have transient tics (Koplewicz, 1996). These are tics that come and go. In a minority of cases, the vocalizations can include socially inappropriate words and phrases. This is called coprolalia. These outbursts are neither intentional nor purposeful.

Involuntary movements can include eye blinking, repeated throat clearing or sniffing, arm thrusting, kicking movements, shoulder shrugging, and jumping. As many as 50% of all persons with TS also have symptoms of obsessive-compulsive disorder (McDougle, 1997).

Many children with TS or tic disorders also have other neurobehavioral disorders, such as ADHD or OCD. When a child has both TS and OCD, it is important to distinguish between tics and OCD symptoms because the treatments differ. It is often difficult to tell if a symptom is a tic or an OCD ritual. The major difference is that a tic is preceded by a sensory feeling, while an OCD compulsion is preceded by a thought.

Attention deficit hyperactivity disorder is the most common neurobehavioral disorder in children. Affecting 3% to 5% of children, it occurs four to nine times more often in boys (Koplewicz, 1996). Attention deficit disorder and attention deficit hyperactivity disorder are characterized by inattention and impulsivity – difficulty keeping attention focused on one thing and being susceptible to a broad range of distractions. When attention deficit disorder (ADD) is accompanied by hyperactivity – excessive uncontrollable fidgetiness and inability to sit still to the point of interference with home and school – the term attention deficit hyperactivity disorder (ADHD) is used. While some children with OCD can also have ADD and ADHD, OCD symptoms are often confused with ADD and ADHD. Children with OCD often appear inattentive and distracted when they are focusing on obsessive thoughts. They are often misdiagnosed with ADD and ADHD.

Family involvement is important to anyone as they strive to break free from OCD. To children, family support and involvement is crucial. The family needs to work as a team in the fight against OCD. There are a few other areas where parents can assist their children as they struggle with OCD.

Acceptance and Fairness

Obsessive-compulsive disorder is not fair! It is not fair for the child with OCD, and it is not fair for brothers and sisters. They may feel their sibling gets away with things because of OCD. They’re probably right. Again, education will help the entire family understand OCD behavior. Giving OCD a name helps. Instead of blaming the child, brothers and sisters can blame OCD.

         Structure and Discipline

Structure is very important in any family. Children feel more secure when they know they can depend on a daily routine. Obsessive-compulsive symptoms tend to be more severe when there are life changes. Vacations are fun, but can bring with them a whole new set of obsessive thoughts and compulsive behaviors. A structured environment will benefit the rest of the family also. Set clear rules and expectations. Post them on the refrigerator. State the rules in a positive way. "You will do your homework before watching TV," instead of "No TV until your homework is done." "You may watch TV 2 hours today," instead of, "No more than two hours of TV." Schedule activities. They don't have to be the same every day, but let your child know what the schedule will be for each day. Try to have dinner, homework, and bedtime at the same time most days. What if things get off schedule? Help your child accept the changes. People with OCD tend to dislike changes, but this is a part of life. We need to accept that.

Sometimes children find it less scary to be punished than to fight OCD. Misbehavior could be part of a compulsion or it could be avoidance. Of course, misbehavior may or may not have anything to do with OCD. What about discipline for disobedience that has nothing to do with OCD? Use your stickers! Set up a sticker chart for all the children. Reward positive behavior with a sticker. These behaviors may be different for each child, depending on age, temperament, and personality. Get the children involved in setting goals and choosing behaviors to be rewarded. At the end of each week, give small rewards for the stickers. Accompany stickers and rewards with praise. Even when they don’t earn a reward, give praise for trying.

Children with OCD misbehave too. They need discipline for misbehavior that they can control. As medication and cognitive behavior therapy begin to help, the expectations should be increased. "People will just have to understand – I have OCD." A qualified therapist can help you decide which negative behaviors should be disciplined.

            Homework

The home can turn into a battlefield at homework time. It can be extra frustrating for many children with OCD. There are things you can do to help your child with homework:

A child's teacher and school counselor are important team members in the struggle with OCD, but school personnel may lack knowledge about OCD. As a parent, you can help by providing information to your local schools.

If you have a local Obsessive Compulsive Foundation affiliate or support group, request that a representative provide an in-service presentation at your child's school. This would help school personnel better understand OCD and its management. If no one is available, the video, "The Touching Tree" (also available through the Obsessive-Compulsive Foundation), would improve understanding. It is about a boy with OCD whose teacher recognizes he has a problem and assist him in getting help.

Communicate with your child’s teachers through visits, phone calls and notes. Inform teachers of new symptoms, medication changes, side effects of medications to look for, progress of behavior therapy and things to praise your child for.

Portions of this chapter adapted from a continuing education course for nurses, Obsessive Compulsive Disorder, by Cherlene Pedrick RN. It was published in 1996 by National Center of Continuing Education, Inc.

Geller, Daniel A. 1998. Juvenile Obsessive-Compulsive Disorder. In Obsessive-Compulsive Disorders, Practical Management, edited by Jenike, Michael, et all. St. Louis: Mosby, Inc.

Koplewicz, Harold S. 1996. It’s Nobody’s Fault. New York: Times Books.

Leonard, Henrietta. 1989. Childhood Rituals and Superstitions: Developmental and Cultural Perspective. In Obsessive-Compulsive Disorder in Children and Adolescents, edited by Rappoport, J.L. Washington, DC: American Psychiatric Press. Washington.

March, John and Mulle, Karen. 1998. OCD in Children and Adolescents, A Cognitive-Behavioral Treatment Manual. New York: The Guilford Press.

McDougle, Christopher J. and Goodman, Wayne K. 1997. Combination Pharmocological

Treatment Strategies. In Obsessive-Compulsive Disorders: Diagnosis; Etiology; Treatment, edited by Hollander, Eric, et all. New York: Marcel Dekker, Inc.

Piacentini, John and Grawe, Flemming. 1997. Childhood OCD. In Obsessive-Compulsive Disorders: Diagnosis; Etiology; Treatment, edited by Hollander, Eric, et all. New York: Marcel Dekker, Inc.

Swedo, Susan Anderson and Leonard, Henrietta. 1998. Is it "Just a Phase"? New York: Golden Books.

Yaryura-Tobias, Jose A. and Neziroglu, Fugen A. 1997. Obsessive-Compulsive Disorder Spectrum, Pathogenisis, Diagnosis, and Treatment. Washington DC: American Psychiatric Press.

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