Obsessive-Compulsive Disorder in Children and Adolescents:
Identification and Treatment Options for OCD
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Have you ever heard someone say, “I have OCD,” when referring to themselves being neat and tidy? This represents a common myth about obsessive-compulsive disorder (OCD). While being organized is a very useful way to be, OCD, on the other hand, is a serious and impairing disorder. The rituals of OCD can be time-consuming and exhausting for individuals and their families. As such, it’s important to clarify some of the other common myths about OCD. For one, some are surprised to learn that OCD occurs in children and adolescents; in fact, it’s more common than previously thought, diagnosed in around 1-2% of youth (Lack & Storch, 2014). Also, when considering OCD, people often immediately think of hand-washing. While contamination fears and related compulsions are relatively common presentations of OCD, Obsessive-compulsive disorder has a myriad of other symptoms that are important to recognize. Finally, “checking” things does not necessarily mean that you have OCD. It’s appropriate and often helpful to check to make sure that you locked the door before you leave, and double-check your answers on an important test. Only when checking becomes time-consuming and excessive is it indicative of a disorder like OCD.
What is OCD?
OCD is characterized by repetitive and intrusive thoughts, images, doubts or impulses (obsessions) and accompanying, ritualistic thoughts or actions (compulsions) aimed at relieving distress related to the obsessions. Families of children with OCD may find the compulsions to be not only excessive and time-consuming, but also illogical. Not surprisingly, compulsions may help the child feel better in the short-term, but they tend to maintain anxiety and obsessions in the long-term, and so are counter-helpful (Albano, March, & Piacentini, 1999). Children with OCD often report obsessions related to contamination, harming a loved one, excessive doubting, and unwanted religious or sexual thoughts. Accompanying compulsions can include excessive hand washing, repetitive checking, ritualistic touching or arranging of objects, confessing, and praying. Pediatric OCD occurs more often in males than females (Lack & Storch, 2014).
I am concerned that I/my child may have OCD. What can I do?
As described above, it’s important to recognize that some behaviors, such as checking, are normal and often helpful. These behaviors achieve the level of “disorder” when they 1) cause significant distress to a child and his/her family; 2) are excessive and time-consuming; and 3) lead to significant interference, such as problems at school, with friends, and in families (APA, 2000; APA 2013). If this sounds like what you are experiencing, it’s important to seek treatment from a mental health professional such as a psychologist. While content of the obsessions and compulsions may change over time, OCD typically will not go away on its own without treatment.
Your psychologist will first conduct a careful assessment to determine whether your child meets diagnostic criteria for OCD. The clinician will also assess for any comorbid disorders, given that OCD often co-occurs with anxiety disorders, behavior problems, mood disorders, and tic disorders. The clinician may also wish to know specific details about the nature of the obsessions and compulsions; for example, How often does your child engage in these behaviors? What do they look like? What happens if your child is unable to act out his/her rituals? These questions help the clinician understand the exact nature of the problem, and will inform treatment.
What will treatment look like?
Fortunately, there are effective treatments for OCD. Cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP) is established as the most effective treatment for OCD (Barrett et al., 2008; Storch et al., 2007), although response rates may vary depending on symptom profile. Some subtypes, such as cleaning and checking compulsions, have received more research attention than others, such as multiple-ritual, exactness and hoarding presentations (Ball, Baer, & Otto, 1996; Sookman, Abramowitz, Calamari, Wilhelm, & McKay, 2005).
As with other CBTs, CBT with ERP is typically a goal-oriented and structured approach to treatment. After conducting a careful assessment, the psychologist, will likely then work with the child to learn coping skills (e.g., cognitive techniques) to manage the symptoms. The ERP part of treatment includes helping the child gradually face his or her fears while refraining from the compulsive behavior. For example, a child with contamination fears may be asked to touch something “dirty,” and then refrain from hand-washing for a while. A goal of ERP is to teach the individual that, with repeated exposure to the feared object or behavior, the obsession-triggered anxiety will dissipate. As the individual reaches habituation, s/he learns that the feared consequences of not ritualizing will not materialize (Barrett, Farrell, Pina, Peris, & Piacentini, 2008). While this may seem daunting at first, the therapist usually takes a gradual approach, starting with less difficult tasks and slowly increasing the difficulty over time. The therapist may model the task prior to having the child engage it in, and always ensures the safety of the child.
Importantly, OCD is often a family problem. It’s natural to want to protect your child from distress. As a result, parents and siblings may find themselves allowing the compulsions, or even performing the compulsions with the child, in order the prevent the child from becoming anxious. Actually, while accommodating the youth’s fears may help at first, it may make the OCD worse over time. Therefore, families are usually an essential part of treatment, especially for younger children. Also, CBT extends beyond the therapy room. It’s likely that your child will have “homework” to complete in between therapy sessions. Your therapist will work with you and your child to practice things learned in therapy at home.
Are there medications that can be effective?
Unfortunately, only a partial response is usually achieved by medication alone, and some symptoms usually persist. There has been research comparing the rates of successful outcomes with the combination of brief cognitive-behavioral therapy and medication, full courses of cognitive behavioral therapy and medication, and medication alone. The best outcomes were achieved with combination of medication and a full course of cognitive-behavioral treatment, with nearly 70% showing significant improvement, compared to a rate of only about 30% with medication alone (Franlkin, et.al, 2011).
Books for Parents:
· Freeing your child from Obsessive-Compulsive Disorder: A powerful, practical program for parents of children and adolescents by Chansky
· Talking back to OCD: The program that helps kids and teens say “no way” – and parents say “way to go” by March & Benton
Books for Children and Adolescents:
- Up and Down the Worry Hill by Wagner.
- Kissing Doorknobs by Hesser (for young adults)
- What to do when your brain gets stuck: A kid’s guide to overcoming OCD by Huebner
Albano, A. M., March, J. S., & Piacentini, J. (1999). Cognitive behavioral treatment of obsessive-compulsive disorder. In R. T. Ammerman (Ed.), Handbook of prescriptive treatments for children and adolescents (pp. 193-213). Boston: Allyn & Bacon.
American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Ball, S. G., Baer, L., & Otto, M. W. (1996). Symptom subtypes of obsessive-compulsive disorder in behavioral treatment studies: A quantitative review. Behavior Research and Therapy, 34, 47-53.
Barrett, P. M., Farrell, L., Pina, A. A., Peris, T. S., & Piacentini, J. (2008). Evidence-based psychosocial treatments for child and adolescent obsessive-compulsive disorder. Journal of Clinical Child and Adolescent Psychology, 37, 131-151.
Lack, C. W., & Storch, E. A. (2014). Obsessive-compulsive disorder in children. In L. Grossman & S. Walfish (Eds.), Translating Psychological Research Into Practice (pp. 65-67). New York: Springer Publishing Company.
Storch, E. A., Geffken, G. R., Merlo, L. J., Mann, G., Duke, D., Munson, M., et al. (2007). Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Comparison of intensive and weekly approaches. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 469-478.
Sookman, D., Abramowitz, J. S, Calamari, J. E., Wilhelm, S., & McKay, D. (2005). Subtypes of obsessive-compulsive disorder: Implications for specialized cognitive behavior therapy. Behavior Therapy, 36i, 393-400.
Franklin, M.E., Sapyta, J., Freeman, J.B., Khanna, M., Compton, S, Almirall, D., Moore, P., Choate-Summers, M., Garcia, A., Edson, A.L., Foa, E.B., March, J.S. Cognitive Behavior Therapy Augmentation of Pharmacotherapy in Pediatric Obsessive-Compulsive Disorder. The Pediatric OCD Treatment Study II (POTS II) Randomized Controlled Trial. JAMA. 2011;306 (11):1224-1232.
About the Author:
Dr. Colleen Cummings completed her doctorate in clinical psychology with a specialty in child psychology from The Ohio State University. She completed her American Psychological Association-accredited internship training in clinical child psychology at the Children's National Medical Center in Washington, D.C. and postdoctoral research and clinical work at the Temple University Child and Adolescent Anxiety Disorders Clinic in Philadelphia, Pennsylvania. She is an expert in evidence-based treatment for childhood and adolescent anxiety disorders, incorporating cognitive-behavioral techniques in her therapy.
Dr. Cummings practiced as a licensed psychologist in the State of Pennsylvania since 2011 before becoming a licensed psychologist in Florida. Update 11/24/14: Colleen Cummings, Ph.D. now practices as a licensed psychologist in Rockville, Maryland. Her practice website link is: http://www.alvordbaker.com/.