Diseases & Conditions
Obsessive-compulsive disorder (OCD)
An anxiety disorder in which the brain gets “stuck” on a particular thought or urge and cannot let go, leading to obsessive thinking or beliefs. All children worry, but a child who cannot stop thinking about these worries—and who may begin to perform certain rituals over and over again—may be diagnosed with obsessive-compulsive disorder (OCD).
About one million children and teens in the United States experience OCD—or one in every 200 American children. It is more common than many other childhood disorders or illnesses, but the child often hides the behavior because it causes pain and embarrassment.
For years thousands of children were undiagnosed because OCD had been considered an “adult” problem. Instead of getting treatment, children with OCD were called dumb, lazy, or easily distracted and were often misdiagnosed as learningdisabled or autistic. Even today many children’s symptoms are overlooked. The danger of leaving the disorder untreated (besides school failure and lack of friends) is that children with OCD grow up to ease their pain by abusing drugs and alcohol.
OCD is not a neurosis as it was long thought to be, nor is it caused by overcontrolling parents. The disorder is related to a chemical problem in the brain that occurs when part of the brain that ?lters information does not function properly, causing certain thoughts to return over and over. It can run in families, although it seems that genes are only partly responsible for the condition. (If one identical twin has OCD, there is only a 13 percent chance that the other twin also has the condition.) No one knows for sure what triggers OCD, but some experts believe that OCD may be linked to infections with streptococcal bacteria.
Some experts suspect that there may be different types of OCD, and that some types are inherited while other types are not. Preliminary research suggests that OCD that begins in childhood may be different from OCD beginning in adulthood. Individuals with childhood-onset OCD appear much more likely to have blood relatives affected with the disorder than do those whose OCD ?rst appears in adulthood. If one parent has OCD, the likelihood the child will be affected is about 2 to 8 percent; if the parent also has blood relatives with the disorder, the risk for the child increases somewhat. If the parent’s OCD began in adulthood, then any children are at lower risk than if the parent’s condition began in childhood.
Not all children with OCD behave the same way. The most common symptom is fear of germs. For schoolchildren, that often means an inability to touch chalk, erasers, and papers; some will not take their backpacks or shoes into the house. However, most children with OCD perform well in school. Sometimes a child’s A’s are the result of an obsession for perfection. These children seemingly are never satis?ed with their work and insist on doing it over and over. A child may stay up all night doing a simple assignment. Other symptoms range from mild to severe, forcing children to endlessly wash hands, kiss doorknobs, walk on the sides of their feet, insist that the window blinds be at a speci?c height, or repeatedly rebutton clothes or retie shoes. Some are haunted with images of violence and danger. Children with OCD struggle in school, where they are often teased and may suffer emotional and physical dysfunction.
The most common obsessions in children and teenagers with OCD include:
• fear of dirt or germs
• fear of contamination
• fear of illness or harm
• need for symmetry, order, and precision
• religious obsessions
• preoccupation with body wastes
• sexual or aggressive thoughts
• preoccupation with household items
• intrusive sounds or words
The following compulsions have been identified as the most common in children and adolescents with OCD:
• grooming rituals (excessive hand-washing, showering, and teethbrushing)
• repetition (such as going in and out of doors, 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 counteract contact with a “contaminated” person or object
• “touching” rituals
• rituals to prevent harming self or others
• arranging objects and counting rituals
• hoarding and collecting things
• cleaning rituals related to the house or other items
The disorder is often accompanied by TOURETTE’S SYNDROME, a neurological disorder characterized by involuntary movements and vocal tics. Between 35 percent and 50 percent of people with Tourette’s syndrome also have OCD, but only a small percentage of children with OCD also have Tourette’s syndrome.
Other conditions that often occur in conjunction with OCD include other ANXIETY DISORDERS (such as panic disorder or SOCIAL PHOBIA), depression, disruptive behavior disorders (ATTENTION DEFICIT HYPERACTIVITY DISORDER and OPPOSITIONAL DEFIANT DISORDER), LEARNING DISABILITY, TRICHOTILLOMANIA (compulsive hair pulling), body dysmorphic disorder (imagined ugliness), and habit disorders such as NAIL BITING or skin picking.
OCD can be detected with positron emission tomography (PET) scans or magnetic resonance imaging (MRI), which can show the chemical functioning or structure of the brain. Research suggests that OCD patients have patterns of brain activity that differ from people without the condition.
Most children, but not all, show improvement with behavioral therapy, medication, or both, given in a consistent, logical, and supportive manner. Cognitive-behavioral therapy (CBT) helps children learn to change their thoughts and feelings by changing their behavior. With this treatment, the child is exposed to his fears to decrease his anxiety about it while blocking his response or rituals. For example, a child who is afraid of germs might be exposed to something he considers dirty while not being allowed to wash. In some treatment methods, the child gives OCD a nasty nickname and visualizes it as something he can control. Behavioral treatment with children works best when the whole family is involved.
Although many children respond to therapy alone, others need a combination of therapy and medication. Medication is often combined with CBT to get more complete and lasting results. Research shows that the newest antidepressant, called selective serotonin reuptake inhibitors (SSRIs), are most effective in children with OCD. These include medications such as fluoxetine (Prozac), ?uvoxamine (Luvox), paroxetine (Paxil), citalopram (Celexa), and sertraline (Zoloft). Another medication that may be prescribed is clomipramine (Anafranil). Most experts agree that medication should be used to treat children as a second choice to behavior therapy. Medication can reduce the impulse to engage in ritualistic behavior while therapy helps the child and family learn strategies to manage the waxing and waning of OCD symptoms.
Only four OCD medications have U.S. Food and Drug Administration (FDA) approval for use in children and adolescents: clomipramine (Anafranil), fluvoxamine (Luvox), sertraline (Zoloft), and Prozac. Clomipramine has approval for children age 10 and over; ?uvoxamine has approval for children aged eight and above. The FDA grants speci?c approval for use in children after large studies using pediatric patients have been completed. Because these large studies are very expensive and dif?cult to accomplish, they have not been conducted with all OCD medications. Doctors may still legally prescribe any of the ?ve available medications to children of any age they deem appropriate (called “off label use”). However, most physicians prefer to use medication the FDA has speci?cally approved for use in children.
Because OCD is a chronic condition that medications do not typically cure, a child may need to take medication indefinitely. Typically, when medication is withdrawn, the OCD symptoms return to their pre-drug level. Many physicians recommend that if the medication is working well, it should continue for at least a year. After a year, the dose can be slowly lowered to see if it is still helpful; this is often done during summer vacation or when an increase in OCD symptoms would be least likely to be disruptive. If OCD symptoms return, the dose is raised again.