Defining the ProblemAccording to the American Psychiatric AssociationDiagnostic and Statistical Manual of MentalDisorders, Fourth Edition, (DSM-IV) obsessivecompulsive disorder (OCD) is an anxiety disordercharacterized by recurrent obsessions or compul-sions that are severe enough to be time consuming(more than one hour per day), cause distress, or interfere with a child’s normal routine, academicfunctioning, social activities or relationships. Obsessions are defined as persistent ideas,thoughts, impulses, or images that are experienced as intrusive and inappropriate; they are notsimply excessive worries about real-life problems. Obsessive behaviors included in the definitionare repeated thoughts about contamination, doubts, a need to have things in a particular order,aggressive or horrific impulses, and sexual imagery. Compulsions are defined as repetitivebehaviors or mental acts, the goal of which is to prevent or reduce anxiety or stress rather thanto provide pleasure or gratification. Compulsions included in the definition are hand washing,ordering, checking, praying, counting, or repeating words silently. OCD usually involves bothobsessions and compulsions, but it is possible for a child with OCD to have one or the other.

This Instant Help Chart was written byLeslie Burling-Phillips

Research shows thatselective serotonin reuptake

inhibitors (SSRIs) can be aneffective treatment for

OCD. These medica-tions increaseand regulate thelevel of serotoninin the brain.However, when

medication isdiscontinued, symptoms usually returnto the predrug level of severity. InOctober 2004, the Food and DrugAdministration warned that use of anti-depressant drugs, including SSRIs, mayincrease the risk of suicidal ideation andsuicidal behavior in a small number ofchildren and adolescents.

Examples of commonly prescribedSSRIs include:

Anafranil Prozac Luvox Paxil Zoloft Celexa

Occasionally, when SSRIs prove ineffec-tive, the monoamine oxidase inhibitor(MAOI), Nardil, may be prescribed. Itusually takes from two to three monthsof medication treatment to see signifi-cant improvements in OCD symptoms.The success rate of medication alone inthe treatment of OCD is less than 20%.For this reason, medication is almostalways combined with CBT to achieveoptimal results.

Treatment with medication should beconsidered when a child is experiencingsignificant OCD-related impairment ordistress and when CBT is not successful or isonly partially effective. A frequent andongoing evaluation of the child is necessaryto plan, modify, and monitor treatment.Important steps include: Assessment of symptom severity. Review of the success of CBT. Physical and psychiatric evaluation.

Laboratory tests are necessary beforeand during treatment with Anafranil butnot with other SSRIs, particularly for chil-dren with preexisting heart disease.

Consideration of how medication will besupervised at home and school.

Review of possible side effects. Researchindicates that all SSRIs are equallyeffective in the treatment of OCD andhave similar side effects that includenervousness, insomnia, restlessness,nausea, and diarrhea.

The implementation of a monitoringschedule that will collect data on boththerapeutic benefits and side effects.Weekly appointments are usuallynecessary at the beginning of treatmentto develop a treatment plan and tomonitor symptoms, medication doses,and side effects. Once an optimal treat-ment schedule is established, monthlyfollow-up visits are recommended for atleast six months and continued treatmentfor at least one year before attempting todiscontinue medication or CBT.

Counseling the child and parents aboutthe medication, possible side effects,interactions, and adverse withdrawaleffects.

Books for ParentsObsessive Compulsive Disorder: New Helpfor the Family. Herbert L. Gravitz, PartnersPublishers Group, 2004Worried No More: Help and Hope forAnxious Children. Aureen Pinto Wagner,Lighthouse Press, 2005Freeing Your Child from Obsessive-Compulsive Disorder: A Powerful, PracticalProgram for Parents of Children andAdolescents. Tamar E. Chansky, ThreeRivers Press, 2001

What to Do When Your Child HasObsessive-Compulsive Disorder: Strategiesand Solutions. Aureen Pinto Wagner,Lighthouse Press, 2002Helping Your Child with OCD: A Workbookfor Parents of Children with Obsessive-Compulsive Disorder. Lee Fitzgibbons andCherry Pedrick, New Harbinger, 2003

Books for Children and TeensUp and Down the Worry Hill: A Children’sBook about Obsessive-CompulsiveDisorder and Its Treatment. Aureen Pinto

Wagner and Paul A. Jutton, LighthousePress, 2004A Thought Is Just a Thought: A Story ofLiving with OCD. Leslie Talley, LanternBooks, 2004Mr. Worry: A Story about OCD. Holly L.Niner and Greg Swearingen, AlbertWhitman and Company, 2004

Books for ProfessionalsObsessive Compulsive Disorder: Theory,Research, and Treatment. Richard P.Swinson,et al (Eds.), Guilford Press, 2001

Treatment of Obsessive CompulsiveDisorders. G. Steketee, Guilford Press, 1996Cognitive Therapy for Obsessive-Compulsive Disorder: A Guide forProfessionals. Aaron T. Beck, NewHarbinger, 2006 releaseCognitive-Behavioral Therapy for OCD.David A. Clark, Guilford Press, 2003OCD in Children and Adolescents: ACognitive-Behavioral Treatment Manual.John S. March, Karen Mulle, GuilfordPress, 1998

Resources for Helping Children and Teens with OCD

Medication Protocol

Instant Help forChildren and Teens withObsessive Compulsive Disorder

Instant Help forChildren and Teens with Obsessive Compulsive Disorder

This chart is intended to provide asummary of the critical informationavailable on helping children with OCDto insure that every child gets themost appropriate and comprehensiveconsideration.

There are no laboratory tests todetermine the presence of OCD.Therefore, a number of sources areused in the basic assessment of achild’s symptoms. Assessment shouldminimally include: Direct observation of the child Interviews with the child, parents,

and teachers Review of school records and

reports Verbal reports from classmates

and friendsA more thorough assessment mightalso include: Structured interviews with the child Intelligence and achievement

testing to determine the need ofspecial education services

Mental status examinationCommonly used assessment toolsinclude: Clark-Beck Obsessive Compulsive

Inventory, Harcourt Children’s Yale-Brown Obsessive-

Compulsive Scale, Plenum Maudsley Obsessive-Compulsive

Inventory, Plenum State Trait Anxiety Inventory I and II,

Consulting Psychologists Press Beck’s Depression Inventory,

Basis-32, Psychological Corporation Beck Anxiety Inventory, Harcourt Fear of Negative Evaluation

Survey, Lexi-CompA complete evaluation should gatherinformation from multiple sources.

Assessing OCD

About Instant Help Charts

Counseling Children andTeens with OCDThe most effective treatment for children andteens with OCD appears to be exposure andresponse prevention (E/RP) with cognitivebehavioral therapy (CBT). Children learn tochange their thoughts and behaviors throughrepeated exposure to anxiety-provoking stimuli.

CBT is usually implemented in 13–20 weeklyindividual or family sessions, depending onthe child’s age. The therapist and child worktogether to determine the child’s comfort leveland ability to participate in anxiety-provokingsituations. In addition to practicing newlyacquired skills in the therapist’s office,children are given “homework” so they canpractice new skills in real-life situations. A newtreatment plan is developed each week basedon the child’s improvement.Specific skills are taught through: Gradual exposure to OCD-provoking

situations Self-talk exercises that intentionally

elicit obsessive thoughts while refrainingfrom acting on the resulting compulsiveresponse

Relaxation techniques Self-administered positive reinforcement Modeling and shaping the desired behavior

Goals in Developing a Treatment Plan To reduce obsessive thoughts and

compulsive behaviors To develop methods to keep symptoms

from affecting school and socialfunctioning

To assimilate isolated children byteaching them prosocial skills

To teach family members how to slowlystop participating in the child’s OCD-related rituals without causing anxiety inthe child

Medication and OCD

Although the precise neuropsychological causes of OCD areunknown, research indicates that there is increased activityin the frontal lobes, basal ganglia, and cingulum of theOCD-affected brain. These brain structures use the

chemical messenger serotonin for communication. It isbelieved that abnormal levels of serotonin are involved in OCD.

The Brain and OCD

(continued on p. 2)

4 • Instant Help for Children and Teens with Obsessive Compulsive Disorder

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Because OCD tends to get worse without treatment, it gradually disrupts a child’s behaviormore and more. Hiding these behaviors becomes complex and stressful, and they may onlybecome apparent long after the child first began experiencing the signs of OCD. Althoughfamilies do not actually cause OCD, family members’ reactions to the disorder affect thesymptoms. Factors within the family dynamics that can intensify OCD behaviors include arecent family move, divorce, new stepparent or stepsiblings, changes in school, death of afamily member or close friend, as well as other anxiety-inducing situations.

There are several things that parents can do to help children with OCD:

1. Reduce the child’s OCD behaviors.Everyone in the family must be educated about the disorder so they can recognize the symptoms of OCD and help the child controlcompulsive behaviors.

2. Determine how their parenting style may contribute to the child’s behaviors.Punishment and negative feedback for OCD-related behaviors can create stress and increase symptoms. Instead, parents should focuson accomplishments and reinforce the child’s attempts to control OCD symptoms.

3. Reduce family and environmental stressors that contribute to the child’s behavior.This includes establishing daily routine and a calm, structured environment with clearly defined rules. Parents must eliminateunnecessary sources of stress in the child’s home and outside environment and be willing to make changes in the family lifestyle toaccommodate the child with OCD.

4. Develop a support system of openness and understanding.Children need to feel comfortable talking about their symptoms and how those symptoms affect them. Parents must create a line ofcommunication with their children that does not involve criticism or punishment for OCD behaviors.

DON’T

• Make negative comments about OCD-relatedbehaviors.

• Ignore the signs and symptoms of OCD.

• Refuse to participate in the symptoms.

• Criticize thoughts or actions associated with thechild’s OCD.

• Make unexpected changes in the child’s routine.

• Blame the child for the OCD behaviors.

• Assume you know how the child is feeling.

DO• Offer calm, understanding support.• Learn as much as you can about the disorder and

discuss it with the child.• Work with the child in developing a strategy to disen-

gage you from participating in OCD-related behaviors.• Praise successful attempts to resist OCD.• Discuss any changes that may directly or indirectly

affect the child.• Reassure the child that the symptoms can be

overcome.• Listen to the child and ask what you can do to help.

2 • Instant Help for Children and Teens with Obsessive Compulsive Disorder

What Parents Need to Know

Teachers are often the first to become aware of a child’s or teen’s compulsive behavior but maymisattribute the child’s actions to laziness or stubbornness. Refusal to attend school, repeated tardi-ness, poor concentration, excessive focus on having belongings neat and tidy, frequent trips to thebathroom, avoidance of physical contact with others, repeated sharpening of pencils, and slow,deliberate, or partial completion of assignments are all common examples of how a child mayexhibit signs of OCD in the classroom. With an understanding of OCD, teachers can help childrenfind effective ways of managing their maladaptive behaviors, without adding undue pressure thatcould make the symptoms worse. Accommodating the behaviors related to OCD is essential. Hereare some ways that teachers can assist children with OCD: Reducing triggers of compulsive rituals

Situations that provoke anxiety, such as unclear expectations, complex assignments, or changes in schedule,are likely to triggercompulsive rituals. Giving the student clear explanations, making assignment modifications, and providing advanced notification ofchanges in the regular class routine are accommodations that can help the student with OCD.

Time managementTeachers should allow adequate time for completing tasks, assignments, and tests. Make a contract with the student detailing what isacceptable: how much time is allotted to complete the assignment; how much rewriting is permissible; and whether in-class assignmentsmay be completed at home.

Communication with the OCD studentTeachers should frequently talk with the student determine what support or assistance might be needed. Develop strategies for dealingwith negative social situations or confrontations.

RedirectionRather than using punishment, a system for redirecting the student’s behavior should be implemented.

Development of a support systemDesignate a mentor within the school system who understands OCD and can be available for the student to regularly talk with.

Educating classmatesConduct a peer education programs, designate a “study buddy,” and structure class activities so that students with OCD who have troublewith peer relationships or are socially isolated are involved.

Teachers should communicate with the child’s therapist to find out what the treatment plan involves and how the school might help thestudent. Work with the child and the family to help reduce OCD symptoms by using suggested treatment plans. If the disorder significantlyinterferes with learning or behavior, children with OCD may qualify for special education services.

Instant Help for Children and Teens with Obsessive Compulsive Disorder • 3

The incidence of the disorder is higheramong first-degree relatives of childrenwith OCD, particularly fathers. However,children who develop OCD generallyexperience different symptoms fromthose experienced by family members.For example, a child with OCD may beobsessive about germs and compul-sively wash his hands. The child’sfather may be obsessive about orderand compulsively arrange the garage.

Estimates suggest that OCD occurs inapproximately 1 in 100 children andequally affects both males and females.

Some cases of OCD may be associatedwith streptococcus infection in children.These cases, referred to as PediatricAutoimmune NeuropsychiatricDisorders Associated with StreptococcalInfections (PANDAS), are characterizedby an abrupt onset of OCD symptomsafter a strep infection. Antibiotics maybe helpful.

In about 50% to 70% of cases, onset of

OCD symptoms occurs after a stressfulevent; for example, the remarriage of aparent or death of a relative or friend.

Fear of contamination is thought to bethe most frequent obsession associatedwith OCD. An overly exaggeratedawareness of germs, disease, or dirtresults in compulsions performed toreduce the existence of these “feared”contaminants. Excessive hand washingand cleaning are commonly associatedescape compulsions. Other commoncompulsions are counting, checking,and hoarding; these are usually relatedto obsessions involving moral doubts,loss of control and order, respectively.

Children with OCD may experiencestress-related symptoms, such asheadaches and upset stomachs. Thesemay be related to inadequate sleep orpoor nutrition resulting from the timeand effort needed to performcompulsive rituals.

Most children with OCD experiencepathological doubts, such as “If I don’tdo this, something bad will happen (tome, my family, etc.).”

Fast FactsThe Dos and Don’ts of Communicating

What Teachers Need to Know

Defining the Problem (continued)

The signs and symptoms of OCD vary inboth type and severity among children andcan begin as early as age two. Younger chil-dren may not recognize that their beliefs oractions are illogical; those who do are oftensecretive about their symptoms. For thisreason, OCD often goes unrecognized andtherefore undiagnosed. Without treatment,OCD is usually a lifelong problem with symp-toms improving and worsening periodically.

It is estimated that at least one-third ofchildren with one anxiety disorder meet thecriteria for two or more anxiety disorders.Conditions usually comorbid with OCDinclude other anxiety disorders, depression,disruptive behavior disorders, learningdisorders, tic disorders, trichotillomania, andbody dysmorphic disorder.

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