DR. STORCH is associate professor in the departments of pediatrics and psychiatry, University of Florida, Gainesville. He
has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest
in any part of this article.
We all recall our childhood days of avoiding stepping on cracks so as not to "break our mother's back" or insisting that our
father check under the bed every night to ensure the absence of monsters. Repetitive play, superstitions, and ritualistic
games are typical aspects of child development. However, parents and pediatricians alike often face the question of when these
behaviors cross the line from normal to worrisome—that is, when they may indicate obsessive-compulsive disorder (OCD).
OCD is characterized by intrusive, troubling thoughts (obsessions) and repetitive, ritualistic behaviors (compulsions).1 These behaviors aim to reduce anxiety typically brought on by obsessional thinking. Patients with OCD experience obsessions
or compulsions, or both, that are time consuming (take more than one hour per day), significantly impair functioning, or cause
distress.1 Many symptoms of childhood OCD resemble those in adults, but children are not required to view their symptoms as nonsensical
to meet diagnostic criteria.2
OCD has a 3:2 male preponderance3 and begins in childhood in as many as 80% of cases.4 Studies of pediatric OCD have consistently identified the mean age of onset at approximately 10 years;5 without treatment, OCD persists into adulthood6 and is associated with long-term negative outcomes, such as psychiatric comorbidity and reduced social functioning.7 The occurrence of pediatric OCD is likely higher than current estimates of approximately 1% to 4%8,9 because of children's tendency toward secrecy in reporting embarrassing thoughts and behaviors, limited insight, inability
of parents to recognize the symptoms of OCD, spontaneous remission, and lack of awareness about the availability of effective
treatment.
The symptoms
OCD is believed to be significantly underdiagnosed because of practitioners' lack of familiarity with the symptoms, overshadowing
by other disorders (such as disruptive behavior), and the embarrassment many youth feel about their symptoms. Indeed, Jenike
has described OCD as a "hidden epidemic."10
As in adults, the clinical presentation of pediatric OCD is heterogeneous. Common obsessions include fears of harm, contamination,
religious fears, and need for symmetry. Common compulsions include washing and cleaning, repetition of routines, reassurance
seeking, and ordering and arranging.11 Approximately 20% of affected youth have compulsions without obsessions.12,13
Not surprisingly, parents often report that symptoms cause difficulties at school, at home, and in social relationships.14,15 Eighty percent to 92% of parents of children with OCD say that their child has significant problems with academic and family
functioning.
Comorbid psychiatric conditions
High rates of comorbid conditions have been documented in pediatric OCD patients.13,16,17 As many as 60% to 74% of children with OCD have at least one comorbid psychiatric illness, and approximately 30% have two
or more. Anxiety disorders, attention deficit hyperactivity disorder (ADHD), and tic disorders are the most common, although
the exact rates are a matter of debate. Some have suggested modest rates of ADHD and disruptive behaviors (20% and 11% respectively),16,17 whereas others have noted significantly higher rates (48% and 33%).13,18 Rates of major depression and dysthymia have been estimated at approximately 10% to 15%.13,16
Is it normal behavior or OCD?
It is often difficult to differentiate behaviors that fall within the spectrum of normal and those that are problematic. Common
childhood rituals and superstitious behavior include checking under the bed before going to sleep, touching walls ritualistically
while walking, stepping on sidewalk cracks (or avoiding them), or repetitively asking "Are we there yet?" on family car trips.
Many young children also experience developmentally normal fears including fear of strangers, the dark, monsters, or animals.19
Key Points: Obsessive-compulsive disorder in children
|
At around 2 years of age, ritualistic behaviors may include rigid routines related to eating, bathing, and bedtime. At 3
to 5 years, repetitive themes often appear during solitary play, such as crashing cars together repeatedly. At 5 or 6 years,
children may play group games involving elaborate rules and rhymes. Children aged 6 to 11 years may participate in superstitious
games, such as not stepping on a crack to avoid "breaking your mother's back." Older children and adolescents may exhibit
a preoccupation with popular activities, famous people, or sports-related rituals.
Some experts suggest that extreme degrees of ritualistic activity may be viewed as obsessive-compulsive behavior.20 The line between normal and problematic behavior is not always clear, however. Although the mechanism by which some fears
or rituals become pathologic is not completely understood, clinicians and researchers have begun to differentiate between
normal and problematic behaviors. Considerations in making the distinction include assessing how often the child engages in
the behavior, how much the behavior disrupts his (her) daily routine, and how distressed he (she) becomes when the behavior
is interrupted or prevented.
The child's cognitive perspective and emotional responses also help determine whether a behavior is normal or pathologic.
For example, a child with OCD may distinguish between his "normal" superstitions and OCD symptoms by saying that the superstitions
focus on things relating to "good and bad luck," whereas the OCD symptoms involve a preoccupation with danger or contamination.21 Children with OCD are generally significantly distressed by their obsessions and compulsions, whereas children who do not
have OCD tend to feel neutral or positive about their ritualistic behavior. There may be exceptions to this "rule," however,
so it is important to consider how much time the child spends involved in the ritualistic behavior and how upset he becomes
when prevented from engaging in it.
Assessment in primary practice
As the prevalence and severity of pediatric OCD have drawn increased attention from researchers and clinicians, a number of measures have been developed to assess OCD symptoms in children. Although some of these measures are inappropriate
for routine clinical practice for a variety of reasons (time to administer and score, training needed), others may provide
useful information in an efficient manner. The Children's Florida Obsessive Compulsive Inventory,22 which takes about five minutes to complete, asks the child to rate the presence of common obsessions and compulsions. The
Child Behavior Checklist23 allows parents to rate their child's behavior in a number of domains, including anxiety, social withdrawal, and oppositionality.
In combination with its OCD subscale,24 this questionnaire provides valuable information about the child's overall psychosocial adjustment.
In addition to using structured questionnaires, I recommend asking a couple of brief questions that specifically assess the
presence of obsessions and compulsions. Ask the questions when a parent reports significant anxiety or fear in their child
or when you observe the child engaging in repetitive behaviors (handwashing, seeking reassurance) or exhibiting excessive
fears. Examples include: "Does your child ever have bad thoughts over and over about things like being contaminated by germs
or dirt, or does he hear songs or sentences in his (her) head repeatedly?" and "Does your child have to do certain things
over and over again, even though they might seem silly?" Affirmative responses to either question may prompt more thorough
questioning.
If you remain concerned after further investigation, I recommend referring the child to a psychologist with expertise in cognitive
behavior therapy (CBT) or a child psychiatrist knowledgeable about treatment of anxiety disorders. Because as many as 5 million
Americans with OCD do not have access to mental health providers trained in CBT, you may have to refer the family to a provider
with the relevant expertise who treats adults or to a specialty center some distance away that can provide intensive outpatient
or inpatient services.
Effective treatment approaches
Untreated pediatric OCD is associated with significant short- and long-term disruption in functioning. Fortunately, existing
treatments have strong empirical support in both controlled and real-world settings. Cognitive behavioral therapy and pharmacotherapy
with a selective serotonin reuptake inhibitor (SSRI) have emerged as first-line interventions.25
Cognitive-behavioral therapy
for OCD is distinct from other "talk therapies" in that it incorporates a structured approach to teaching the family skills
to use in responding to symptoms. Whereas play-based, supportive, and psychoanalytic therapies have not been demonstrated
to be effective treatments for OCD, many trials strongly support the efficacy of CBT, including excellent maintenance at follow-up.
A randomized trial of CBT and clomipramine in children, for example, found CBT to be superior.26 More recently, a large-scale, multisite, randomized, placebo-controlled trial of CBT, sertraline, and concomitant CBT and
sertraline in children with OCD indicated that either CBT alone or sertraline alone was superior to placebo. However, OCD
symptoms were more likely to diminish in patients receiving CBT alone or in combination with sertraline.27
Treating pediatric OCD with CPT is based on the idea that obsessions and compulsions are functionally related—that is, compulsions
are performed to reduce or avoid anxiety associated with obsessions. Treatment comprises three interrelated core components:
- exposure (placing the patient in situations that elicit anxiety related to obsessions)
- response prevention (deterring the ritualistic or compulsive behaviors that may serve to reduce or avoid anxiety)
- teaching objective thinking strategies, such as training the child to identify and correct anxiety-provoking cognitions.
Exposure relies on the gradual reduction of anxiety by placing the patient in the presence of a feared or ritual-provoking stimulus.28 For example, a child who fears being contaminated with germs by using public toilets would be instructed to touch bathroom
items that provoke anxiety, such as doorknobs, sinks, and toilet seats. Successive exposures to the stimulus both decrease
elevations in anxiety and result in more rapid attenuation of distress during future exposures.
Response prevention is based on the assumption that rituals and compulsions serve as short-term anxiety reducers by means of negative reinforcement
(escape or avoidance of distress). Because children with OCD perform rituals to reduce anxiety, they never experience natural
anxiety reduction (without performing the ritual). Response prevention requires that the child avoid engaging in the ritual
so that anxiety can be reduced by habituation instead. In the example of the child afraid of contamination from toilets, the
child would systematically touch a "contaminated" item without engaging in ritualistic washing.
Teaching the child to use objective thinking strategies in response to anxiety is based on the premise that anxious thoughts arise from inaccurate conclusions or interpretations
of events. Common themes in the thoughts of children with OCD include erroneous estimates of danger, responsibility, and probability.29,30 An example I have often seen is the child who believes that he will contract a serious infection (such as HIV) if he touches
a public toilet seat. Cognitive techniques provide the child with objective ways to "talk back" to anxiety-provoking obsessions
in an attempt to reframe such thoughts in a realistic manner. The child might be instructed to ask socratic questions or make
objective, rational self-statements such as: "How many times have I touched a toilet seat and not gotten HIV?" "Others sit
on toilet seats but do not get HIV." "Can HIV be transmitted in this manner?"
At the start of therapy, patient and therapist develop a "fear ladder"—a hierarchical listing of situations the patient avoids
or in which he would find it difficult to inhibit compensatory rituals. In subsequent sessions, the therapist and child (often
with the parents' assistance) progress up the ladder by systematically exposing the child to events that provoke a ritual
while having the child refrain from performing the ritual.
Not surprisingly, some children, particularly those who are oppositional, resist such an exercise. Although the child's willingness
to tolerate the procedure depends on several variables (developmental level, motivation, understanding of the procedure),
the therapist and parents can often mitigate these difficulties by minimizing the rewarding components of symptoms (anxiety
reduction, escape from unpleasant tasks such as school) and providing rewards (for completing therapy homework assignments,
for example).
Cooperation by the family is central to the success of therapy. Family members may accommodate the child's symptoms, and thus
interfere with treatment, by facilitating avoidance of feared stimuli, assisting with ritualistic behaviors, or inadvertently
participating in rituals (providing reassurance, permitting compulsive avoidance of feared stimuli, or tolerating delays associated
with completing the ritual).31 For this reason, therapists often instruct parents and siblings specifically not to help the child perform rituals. In addition
to assisting with extinction and differential reward procedures, families can provide substantial support, serving as the
child's "ally" in battling OCD.32,33
Pharmacotherapy.
The neurochemical theory of the cause of OCD hypothesizes that abnormal serotonin metabolism is implicated in expression
of symptoms. Randomized, placebo-controlled trials of SSRIs (sertraline, fluoxetine, paroxetine, and fluvoxamine) have demonstrated
clinically significant reductions in OCD symptoms in children and adolescents.34 Although results of meta-analyses have found clomipramine—a tricyclic antidepressant (TCA)—to be slightly superior to SSRIs
in reducing OCD symptoms,34 the effectiveness of SSRIs is nevertheless unequivocally established.
SSRIs are well-tolerated by most people with OCD. Their side effects include nervousness, insomnia, restlessness, nausea,
and diarrhea. The most frequent side effects of clomipramine are dry mouth, sedation, dizziness, and weight gain. Although
both SSRIs and clomipramine can cause sexual problems, such as decreased libido, in adolescents, these effects, on average,
occur slightly more often with clomipramine. Clomipramine is also more likely to cause cardiovascular problems such as hypotension
and irregular heartbeat, so children and adolescents with pre-existing heart disease must have an electrocardiogram before
beginning treatment and at regular intervals thereafter.
Because of the adverse antiadrenergic, anticholinergic, and antihistaminergic side effects of TCAs and the EKG and blood-level
monitoring they require, SSRIs (with a relatively minimal side effect profile) are the consensus first-line medication.34-36 The choice of which first-tier psychotropic to use should be based on the patient's medical history, concomitant medications,
and the adverse events profile.31
A clinical response is unlikely within the first several weeks of starting an SSRI. Generally, 10 to 12 weeks at adequate
dosage is necessary to evaluate the efficacy of the medication. Also, poor clinical response to one SSRI does not necessarily
predict failure with others—suggesting that adequate trials of several SSRIs may be indicated before considering augmentation
with another medication.37
Recently, concern has arisen about a link between SSRIs and increased suicidality in children and adolescents. The United
States Food and Drug Administration (FDA) requires that youth being treated with antidepressants for any indication be closely
observed for worsening of symptoms and for agitation, irritability, suicidality, and unusual changes in behavior. Although
such observation is important throughout the course of treatment, it is especially warranted during the initial few months
of a course of drug therapy or when the dose is increased or decreased. Monitoring should include daily observation by family
members and frequent contact with the physician. The FDA also recommends that prescriptions for antidepressants be written
for the smallest quantity of tablets consistent with good patient management, to reduce the risk of overdose.
Despite scant empiric data, second-line pharmacotherapy of OCD in pediatric patients who do not respond to first-tier medications
includes augmentation of SSRIs.38,39 In adults, fairly extensive data support augmenting SSRIs with a low dosage of a dopamine antagonist—such as typical neuroleptics
(haloperidol, pimozide) or atypical neuroleptics (risperidone, olanzapine)—or a benzodiazepine (clonazepam).40 However, the significant undesirable side effects (psychomotor retardation, memory impairment) of neuroleptics and benzodiazepines
should be considered before prescribing the drugs for children. Augmenting SSRIs with lithium, clonidine, or buspirone is
not recommended.41
Obstacles to therapy
Many barriers to effective treatment of OCD remain. One of the greatest is a shortage of professionals trained in CBT.37 Limited access to specialists familiar with CBT may lead to treatment with pharmacotherapy alone or psychotherapies that
have not been demonstrated to be effective, such as play therapy, psychoanalytical therapy, or insight-oriented therapy.
Fewer than 33% of participants in a national survey of 79 clinicians who treat pediatric OCD reported using CBT, despite rating
this modality as an effective approach to treatment.42 Moreover, Flament and colleagues43 found that only 20% of children with OCD were receiving mental health services, and Heyman and associates44 reported that only 36% of families of children with OCD had consulted their general practitioner. Even fewer had been referred
for OCD-specific mental health services.
It is often difficult to connect patients with appropriate therapeutic and informational resources. The primary role of the
pediatrician is to assist with case identification and subsequent referral to a child psychiatrist or psychologist. Psychologists,
psychiatrists, and other mental health professionals adhere to a variety of treatment models. Some, for example, closely follow
a cognitive-behavioral approach like the one described here. Others use a psychodynamic or psychoanalytic approach, or other
approaches unsupported by empirical data. To facilitate optimal care for your patients, it is important to establish a referral
connection with a psychologist trained in using CBT to treat OCD.
If you cannot locate such a practitioner in your vicinity, a number of university-based programs offer intensive outpatient
or residential treatment programs, with documented effectiveness.45,46 These programs allow families to relocate for several weeks so that the child can receive CBT and pharmacotherapy.
The World Wide Web can be an excellent source of information for families. Two particularly useful sites for general information
and locating treatment providers are the Obsessive-Compulsive Foundation (www.ocfoundation.org) and Anxiety Disorders Association of America (www.adaa.org).
Collaboration is key
It is crucial for pediatricians and mental health professionals to collaborate not only on patient care, but also on educating
each other about their fields of expertise. What's needed is a bridge to close the gap between disciplines and stimulate additional
discussion and scholarship on effective care for children and adolescents with OCD.
Acknowledgment
The author thanks Gary R. Geffken, PhD, for his thoughtful comments. Dr. Geffken and Avani Modi, MS, are co-authors with Dr.
Storch of the Guide for Parents.
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16. Geller DA, Biederman J, Stewart SE, et al: Impact of comorbidity on treatment response to paroxetine in pediatric obsessive-compulsive
disorder: Is the use of exclusion criteria empirically supported in randomized clinical trials? J Child Adolesc Psychopharmacol 2003;13S:S19
17. Swedo SE, Rapoport JL, Leonard H, et al: Obsessive-compulsive disorder in children and adolescents: Clinical phenomenology
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23. Achenbach TM: Manual for the Child Behavior Checklist/4-18 and 1991 profile. Burlington, Vt., University of Vermont, Department of Psychiatry, 1991
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disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry 1998;37:1022
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their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric Obsessive-Compulsive Disorder
Treatment Study Randomized Controlled Trial. JAMA 2004;292:1969
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J Clin Child Psychol 2001;30:8
29. Barrett PM, Healy LJ: An examination of the cognitive processes involved in childhood obsessive-compulsive disorder. Behav Res Ther 2003;41:285
30. Comer JS, Kendell PC, Franklin ME, et al: Obsessing/worrying about the overlap between obsessive-compulsive disorder and
generalized anxiety disorder in youth. Clin Psychol Rev 2004;24:663
31. Snider LA, Swedo SE: Pediatric obsessive-compulsive disorder. JAMA 2000;284:3104
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33. March JS, Mulle K, Herbel B: Behavioral psychotherapy for children and adolescents with obsessive-compulsive disorder:
An open trial of a new protocol-driven treatment package. J Am Acad Child Adolesc Psychiatry 1994;33:333
34. Geller DA, Biederman J, Stewart SE, et al: Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive
disorder. Am J Psychiatry 2003;160:1919
35. Cook EH, Wagner KD, March JS, et al: Long-term sertraline treatment of children and adolescents with obsessive-compulsive
disorder. J Am Acad Child Adolesc Psychiatry 2001;40:1175
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J Am Acad Child Adolesc Psychiatry 2002;41:1431
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38. Simeon JG, Thatte S, Wiggins D: Treatment of adolescent obsessive-compulsive disorder with a clomipramine-fluoxetine combination.
Psychopharmacol Bull 1990;26:285
39. Figueroa Y, Rosenberg D, Birmaher B, et al: Combination treatment with clomipramine and selective serotonin reuptake inhibitors
for obsessive-compulsive disorder in children and adolescents. J Child Adolesc Psychopharmacol 1998;8:61
40. Dougherty DD, Rauch SL, Jenike MA: Pharmacological treatments for obsessive-compulsive disorder, in Nathan P, Gorman JM
(eds): A Guide to Treatments that Work, ed 2. New York, Oxford University Press, 2002, pp 387-410
41. Grados MA, Riddle MA: Pharmacological treatment of childhood obsessive-compulsive disorder: From theory to practice. J Clin Child Psychol 2001;30:67
42. Valderhaug R, Gunnar Gotestam K, Larsson B et al: Clinicians' views on management of obsessive-compulsive disorders in
children and adolescents. Nordic J Psychiatry 2004;58:125
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44. Heyman I, Fombonne E, Simmons H, et al: Prevalence of obsessive-compulsive disorder in the British nationwide survey of
child mental health. Br J Psychiatry 2001;179:324
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open clinical trial. J Am Acad Child Adolesc Psychiatry 1998;37:412
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Case exemplars. Annals of the American Psychotherapy Association 2003;4(6):14
GUIDE for PARENTS
Your child's fears, rituals, and superstitions: When should you worry?
You may remember, as a child, avoiding stepping on cracks so as not to "break your mother's back" or insisting that your dad
check under the bed every night to make sure no monsters lurked there. Repetitive play, superstitions, and ritualistic behaviors
such as asking parents "Are we there yet?" are normal parts of child development. But sometimes, parents and doctors face
the question of when these behaviors cross the line from normal to cause for worry—specifically, concern about obsessive-compulsive
disorder (OCD). This guide provides background information about normal childhood fears and ritualistic behavior and suggests
some questions to ask about your child's behavior that can help you decide whether to seek medical help.
What is obsessive-compulsive disorder?
Obsessive-compulsive disorder is a serious childhood illness characterized by unwanted, troubling thoughts (obsessions), and
repetitive, ritualistic behaviors (compulsions). The child engages in compulsive behavior to reduce anxiety that is typically
brought on by obsessional thinking, but some children have compulsions without obsessions. To be given a diagnosis of OCD,
the child must experience obsessions or compulsions that are time consuming (take more than one hour a day), significantly
interrupt the child's normal routine, or cause significant distress. OCD is somewhat more common in boys than girls. If it
is not treated, it persists into adulthood, causing long-term problems.
Normal superstitions, fears, and rituals
Superstitions are ideas and related practices that people hold in spite of evidence to the contrary. They arise from ignorance
of the laws of nature or faith in magic and chance. They may resemble obsessions and compulsions seen in OCD, but generally
are not considered a problem. People engage in superstitious behavior—such as keeping a four-leaf clover for good luck or
avoiding opening an umbrella indoors to prevent bad luck—regardless of age, gender, or educational background.
Superstitious thinking is characteristic of children between the ages of 2 and 7 years. Common childhood superstitious behaviors
include checking under the bed before going to sleep, touching walls repeatedly while walking, or stepping on sidewalk cracks
(or avoiding them). Many children also experience developmentally normal fears, including fear of strangers, the dark, monsters,
or certain animals.
Most children engage in some type of ritualistic, repetitive behavior. Such behavior occurs most often between 2 and 4 years
of age. It has been suggested that obsessive-like behavior may represent attempts to reduce fears and anxieties related to
growing up.
At approximately 2 years of age, normal childhood rituals include rigid routines regarding eating, bathing, and bedtime. At
3 to 5 years, children often repeat the same themes over and over during solitary play (repeatedly counting or crashing cars
together, for example). At 5 or 6 years, group games often involve elaborate rules and rhymes. Children age 6 to 11 years
may participate in superstitious games (not stepping on a crack to avoid breaking a parent's back). Older children and teenagers
may show a preoccupation with popular activities or famous people or rituals related to competitive sports.
Is it normal behavior or OCD?
Does my child have OCD?
|
Some medical experts suggest that extreme degrees of ritualistic activity may be viewed as obsessive-compulsive behavior.
Unfortunately, the line between normal and abnormal is not always clear. More study is needed, but doctors and researchers
have begun to sort out the differences between normal behaviors and those that may indicate OCD. Specific questions to ask
yourself include: "How often does my child engage in the behavior (how much time and energy does he or she devote to it)?"
"How much does the behavior disrupt my or my child's daily routine?" and "How distressed does my child become when the behavior
is interrupted or prevented?" (see the table).
Often, exploring how your child thinks about the behavior and how he (she) responds emotionally to it can provide clues to
whether or not the behavior is normal. For example, some children with OCD say that their "normal" superstitions focus on
things relating to "good luck and bad luck," whereas their OCD symptoms involve preoccupation with danger or contamination
(as with germs). Children with OCD are generally significantly distressed by their obsessions, rituals, and fears, whereas
children without OCD tend to feel neutral or positive about ritualistic behavior. There may be exceptions to this "rule,"
however, so it is important, as noted, to consider how much time your child spends involved in the ritualistic behavior and
how upset he (she) becomes when the behavior is prevented. If you are having difficulty determining whether or not your child's
behavior is problematic, consider seeking professional help.
How your child's doctor can help
OCD is a serious condition that requires medical attention; stepping on cracks or avoiding them, on the other hand (to return
to what was said at the beginning), is fairly common behavior in normal young children and may not be a sign of OCD. To help
you, and the pediatrician, determine whether your child's behaviors are age-appropriate developmental behavior or indicate
a more serious problem, ask yourself the questions listed in the table below and then talk to the physician about your concerns
and your answers to these questions. Your doctor may want to refer your child to a psychologist or psychiatrist trained in
treating OCD for further assessment.
The author thanks Gary R. Geffken, PhD, for his thoughtful comments. Dr. Geffken and Avani Modi, MS, are co-authors with Dr.
Storch of the Guide for Parents.
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