Diagnosing OCD in Children

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?

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.

Treating OCD in Children

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 for OCD in children 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 (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertaline (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 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 With OCD?

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.

Sources:

• American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC: American Psychiatric Association.
• NIMH Pediatric Obsessive Compulsive Disorder Research Program website
• John S. March, M.D., M.P.H., and Karen Mulle, B.S.N., M.T.S., M.S.W.; OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual, New York City, Guilford Press, 1998
• OC Foundation website, OCD in Children
• Lewis, Melvin (ed.) Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd Edition. Philadelphia: Lippincott Williams and Wilkins, 2002

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