Comprehensive look at Obsessive-Compulsive Disorder in children and adolescents, including symptoms, diagnosis and treatment of OCD in children.

Introduction

At one time, Obsessive Compulsive Disorder (OCD) was believed to be fairly rare. When it was diagnosed, it seemed resistant to treatment. In the past decade, we have learned that it is much more prevalent. Community surveys of adolescents have suggested that at any given time, 1% to over 3% are experiencing symptoms of OCD. Children as young as 5 or 6 can show full-blown OCD. Between 30% and 50 % of adults with OCD reported that their symptoms started during or before mid-adolescence. Fortunately, there are now more effective treatments for OCD. In many ways the symptoms and treatments of OCD in both children and adults follow the same general principles. However, children differ from adults cognitively, developmentally and physiologically. Because of this, we modify techniques based on the particular stage of childhood or adolescence.

Symptoms and Features of OCD

In order to meet DSM-4 criteria for OCD, the individual must have either obsessions or compulsions. In actuality, most children and adolescents have both.

The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-4) defines obsessions as follows:

1. Recurrent and persistent thoughts, impulses or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
2. The thoughts, impulses, or images are not simply excessive worries about real-life problems.
3. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action.
4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

The DSM-4 defines compulsions as:

1. Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

The DSM-4 also requires:

1. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour per day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities.
2. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children

Evaluation

When a clinician is evaluating a child or adolescent for possible OCD, it is important to do a thorough work up. The clinician should meet with the child and ask specific questions about obsessions and compulsions. He or she should also meet with parents or other primary caregivers. Information from school and other outside sources is also useful. If there are obsessions or rituals that occur only at school, it is important to know about them, so that they can be addressed too. The parents and usually the child may also fill out checklists such as the YBOCS (Yale-Brown Obsessive Compulsive Scale) These help to determine the baseline number and severity of the symptoms. Since OCD can be associated with other disorders, the clinician should look other childhood psychiatric disorders.

Most individuals with OCD, even young ones, are at least intermittently aware that their symptoms do not make logical sense. However, young children are less capable of abstract thought, so their degree of insight may not be as good.

Causes

There have been several theories about the cause of OCD. These include psychodynamic, learning theories, and neuro-biological. When we discuss cause, it is important to make it clear that we are looking at Obsessive Compulsive Disorder, not an obsessive, perfectionistic personality style. An obsessive-compulsive personality disorder is different from true Obsessive-Compulsive Disorder. There may be some overlap or it may have a different origin.