Obsessions and Compulsions in Children

(This article was first printed in the July 2002 issue of the Harvard Mental Health Letter. For more information or to order, please go to http://health.harvard.edu/mental.)

Many of us have persistent worries or repetitive routines that seem not entirely sensible, even to ourselves. In people with obsessive-compulsive disorder (OCD), these concerns and habits can become all-consuming and self-destructive. Their obsessional thoughts and impulses and compulsive behavior occupy more than an hour a day or in other ways make them miserable or seriously interfere with their lives. Although it is mainly familiar as an adult problem, OCD is surprisingly common in children. It afflicts 2%–3% of Americans, and between one-third and one-half of them are under 15. The symptoms may appear as early as age three. Childhood OCD is more common in boys than in girls, although the adult form occurs equally in both sexes.

Obsessions are irrational thoughts, images, and impulses that are felt as unrealistic, intrusive, and unwanted—doubts about whether you have done something perfectly, completely, or correctly; an urge to arrange objects carefully in meaningless ways; or a persistent feeling that you are about to do harm to someone close to you.

The thoughts and impulses involve doubt, hesitation, fear of contamination or illness, fear that someone is about to be or has been injured, and excessive concern about obeying social rules or religious prescriptions. People may try unsuccessfully to ignore or suppress their obsessions, or they may feel a kind of relief from compulsive rituals—rigidly repetitive acts aimed at relieving tension and anxiety or preventing the imagined harm suggested by the obsessions.

Common types of compulsive behavior are washing or counting, ordering, checking, touching, making lists, reciting magic words or numbers, and praying. If not treated, symptoms tend to be lasting, although they may come and go, and specific obsessions or rituals may change.

It is normal for children, at various stages of development, to be concerned about sameness and symmetry and having things perfect, to insist on certain bedtime routines, to develop odd superstitions and rituals like avoiding cracks in the sidewalk. But OCD involves much more. Here are some examples:

• A girl constantly prays, traces letters to get them “just right,” and spends hours making sure her homework is perfect.
• A boy spends 2 hours doing gymnastics before bed, repeats words over and over, and won’t eat cereal unless the spoon slips into the bowl at a precise angle.
• A boy buttons and unbuttons his shirt dozens of times before he is satisfied that he can wear it.
• A child uses three rolls of toilet paper for one bowel movement and constantly counts floor tiles or windowpanes.
• A boy feels that a parent will die unless something not done exactly right the first time is done five times, and if not correct then, 25 times.

Even young children often know that their obsessions are senseless, but they are helpless to stop themselves. Compulsive rituals can consume hours a day and interfere with household chores, schoolwork, and normal play. If children try to avoid the situations that provoke the behavior, their lives may become increasingly restricted. As a result, they may become demoralized, and their development may be interrupted.

These children have many other symptoms. Anxiety often accompanies obsessional thoughts. So does depression, partly because it may have symptoms in common with OCD—indecisiveness, rumination, and irrational guilt. About two-thirds of children with OCD will suffer from major depression at some time. They also have a high rate of attention deficit disorder, with its symptoms of hyperactivity (which is sometimes difficult to distinguish from compulsive behavior), distractibility, and impulsiveness.

A group of disorders called the obsessive-compulsive spectrum includes body dysmorphic disorder (delusions of being ugly or physically repulsive), trichotillomania (pathological hair-pulling), and Tourette’s disorder, which consists of motor and vocal tics—blinking, head jerking, throat clearing, grunts, squeals, obscene gestures, and exclamations. About 10% of people treated for OCD have Tourette’s disorder, and many more have some tics.

The Strep Throat Connection

Our understanding of the biology of obsessive-compulsive disorder has been deepened and might eventually be revolutionized by the discovery that similar symptoms may arise from certain common childhood illnesses—the Group-A beta-hemolytic streptococcal infections, which include strep throat and scarlet fever. Today, routine strep infections are easily treated with antibiotics, but the consequences can be serious when antibodies produced by the immune system turn against the body’s own tissues. An inflammation of the heart muscle may cause rheumatic fever, and an attack on the joints may cause arthritis.

In some children, possibly because of a genetic peculiarity of the immune system, the antibodies reach the brain and affect the basal ganglia. Neurological symptoms may result, including Sydenham’s chorea (St. Vitus’s dance). Another, possibly related effect is the condition called pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)—a somewhat controversial diagnosis with reported symptoms that include tics, obsessional thinking, and compulsive behavior, such as handwashing, exaggerated preoccupation with germs, and ritualistic counting inspired by fear that someone will be harmed. These symptoms often appear abruptly after a strep infection and may last several weeks to several months.

Children with PANDAS symptoms are usually treated in the same way as any other child with tics or OCD. Some with severe symptoms that do not respond to the usual treatments have been given intravenous immunoglobulin or plasma exchange (plasmapheresis) to remove streptococcal antibodies from the blood. At least one study has reported that PANDAS symptoms respond to antibiotics if the symptoms are recognized early, but this result is preliminary. The National Institutes of Health is sponsoring further research on PANDAS and its treatment. Whether this condition turns out to be linked to obsessive-compulsive disorder or not, it raises interesting questions about the relationship between common infections, the brain, and behavior.

The Biology of Obsessive-Compulsive Disorder

Obsessive-compulsive disorder runs in families. The lifetime risk for close kin of people with the disorder is 9%, compared with 2% in the general population. The family rate is even higher when symptoms begin in childhood. Studies comparing identical with fraternal twins suggest a heritability (the proportion of individual dif ferences in susceptibility associated with genetic difference) as high as 68%.

Imaging studies show unusual brain activity in patients with OCD, chiefly in a circuit that runs between the frontal lobes of the cerebral cortex and the basal ganglia, a region involved in the control of body movements that is engaged especially for repetitive tasks. Positron emission tomography (PET) scans taken while patients ruminate obsessively or perform compulsive rituals indicate high activity in the orbitofrontal cortex and anterior cingulate cortex, areas important for planning and judgment and the screening of thoughts and sensations for significance.

One theory is that obsessional thinking and compulsive behavior arise when the basal ganglia fail to protect the cortex from receiving information that is irrelevant because it requires no decision or action. A 1998 study found the basal ganglia to be smaller than average in children with OCD, and the smaller it was, the more severe the symptoms. In another study, both cognitive behavioral therapy and drugs prescribed to treat OCD made the basal ganglia less active and seemed to restore normal functioning in the basal ganglia-frontal circuit.

Behavioral Treatment

The standard treatment for OCD at any age is exposure and response prevention—confronting patients with the things, places, and circumstances that provoke obsessions and forbidding performance of the compulsive rituals.

The therapist and patient join in making a list of situations, graded from least to most troublesome, and the level of exposure is gradually increased. The therapist may demonstrate the appropriate behavior first; for example, by holding a dirty towel or touching the floor to show an obsessional child that no harm will come of it. Eventually, if all goes well, habituation reduces anxiety and makes the compulsive behavior unnecessary.

For checking rituals, an alternative is exposure in imagination—having the child refrain from checking after imagining the most feared consequences. When the patient has no compulsive rituals but only obsessions, such as constant worry that a family member will die, response prevention is impossible because there is no action to be avoided. One proposed treatment is satiation—concentrating on the obsessional thoughts for a long time until they lose their compelling quality.

Behavior therapy is usually conducted in weekly sessions for 3–5 months. Daily homework is also important, because the circumstances that provoke obsessions and rituals are different for each person and cannot be easily reproduced in a therapist’s office. Sometimes the best place for therapy is the place where the most serious symptoms occur. Family members are usually enlisted to supervise and encourage patients. After symptoms become less serious, later sessions may be needed to prevent relapse and cope with new obsessions and rituals as they develop.

Older children may also get some help from cognitive therapy, which shows them how to question the significance of their obsessions and the need for their rituals. Cognitive methods are especially useful for children who have what are sometimes called overvalued ideas—obsessions that carry so much conviction they are close to being delusions. A child may not respond well to behavior therapy if, in a corner of his mind, he believes that his parents will die unless he constantly washes his hands. Cognitive therapy is designed to challenge his exaggerated sense of responsibility and fear of catastrophe.

Additional therapies are muscle relaxation, deep breathing, and other techniques of anxiety management. Assertiveness training may help reduce anger, anxiety, or guilt associated with obsessional thinking. Family therapy and insight-oriented or supportive individual psychotherapy cannot cure the symptoms, but may help children and their parents cope with the consequences, including family conflict and misunderstandings. Family support groups are organized by the Obsessive-Compulsive Foundation (see Resources).

Medication

Today, therapists who treat OCD often prescribe medications as well as behavior therapy—and sometimes drugs alone, when behavior therapy is unavailable or too difficult and expensive. Six drugs are thought to be effective: the five selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa) (see Harvard Mental Health Letter , October and November 2000), and the tricyclic antidepressant clomipramine (Anafranil). All of them enhance the activity of the neurotransmitter serotonin by preventing its reabsorption at the nerve endings that release it.

It is not clear how changes in brain activity are related to the effects of serotonin-enhancing drugs. Despite some suggestive preliminary findings, scientists have not confirmed any irregularity in the production, activity, or breakdown of serotonin in children or adults with OCD.

Although clomipramine has been in use longest, most physicians prefer SSRIs, because they are safer and have fewer side effects. In particular, clomipramine can cause irregular heart rhythms and high blood pressure. Children who take it must have periodic heart monitoring. The drugs require two months or more to take effect—a longer time than they usually take to relieve depression, and at doses generally higher than those needed for depression. According to the American Academy of Child and Adolescent Psychiatry, children should keep taking the drug for at least a year and sometimes indefinitely. When the drug is the only treatment, they usually relapse in a few months if they stop.

The rate of improvement in the treatment of OCD is fairly high. Of adults receiving behavior therapy, 75% complete the program, and 75% of them (about 50% overall) improve, with gains persisting 2–3 years. About 50% of adults who take drugs for OCD improve, although the symptoms are rarely eliminated completely. There are fewer controlled studies of childhood OCD, but the response seems to be similar. In one long-term follow-up of 54 children and adolescents treated with clomipramine, researchers found that after an average of 3½ years, 70% (38) were still taking the drug, and 43% (23) still had obsessive-compulsive disorder. Most children improved, but only three (6%) had no symptoms at all. Behavioral treatment is more effective for compulsive behavior than for obsessional thoughts.

Although there are no controlled studies to prove it, many practitioners believe a combination of medication and behavior therapy is best. The drug can help children and parents to take advantage of behavior therapy—or the promise of more permanent relief through behavior therapy may diminish reluctance to take the drug.

Resources

Obsessive-Compulsive Foundation
337 Notch Hill Road
 North Branford  ,  CT   06471 
Telephone:  203-315-2190 
http://www.ocfoundation.org

Provides information and referrals, distributes newsletters, articles, and books, organizes support groups, sponsors a training institute for mental health professionals, and enlists experts to answer questions online.

References

Abramowitz, J.S. “Does Cognitive-Behavioral Therapy Cure Obsessive-Compulsive Disorder? A Meta-Analytical Evaluation of Clinical Significance,” Behavior Therapy (1998): Vol. 29, No. 2, pp. 339–55.

Chansky, T.E. Freeing Your Child from Obsessive-Compulsive Disorder: A Powerful Practical Program for Parents of Children and Adolescents. Three Rivers Press, 2001.

Murphy, M. et al. “Prospective Identification and Treatment of Children with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Group A Streptococci,” Archives of Pediatrics and Adolescent Medicine (April 2002): Vol. 156, No. 4, pp. 356–61.

Practice Parameters for the Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder, Journal of the American Academy of Child and Adolescent Psychiatry (1998): Vol. 37, Supplement 10, pp. 27S–45S.

Rapoport, J. The Boy Who Couldn’t Stop Washing: The Experience and Treatment of Obsessive-Compulsive Disorder. E.P. Dutton, 1988.