Children and Adolescents With Obsessive-Compulsive Disorder.

A Primer for Teachers

Although prevalence rates in the OCD literature vary, it has been estimated that 1 in 200 young persons suffers from obsessive-compulsive disorder - 3 or 4 students in an average-size elementary school.

In the United States, it is estimated that one in every 40 persons suffers from obsessive-compulsive disorder (OCD) (Penzel, 1995), an anxiety disorder characterized by the presence of obsessions or compulsions (American Psychiatric Association [APA], 1994). Once regarded as rare and untreatable, OCD is now considered to be the fourth most common psychiatric disorder among Americans (Rasmussen & Eisen, 1992). Indeed, OCD is so prevalent, yet so secretive, that it has been referred to as a "hidden epidemic" (Jenike, 1989).

OCD is also far more common among children than previously thought. Research indicates that one third to one half of adults with OCD report onset of the disorder during childhood (March & Leonard, 1996). When OCD begins in childhood, it frequently appears between 5 and 8 years of age or during adolescence (Swedo, Leonard, & Rapoport, 1990). Although prevalence rates in the OCD literature vary, it has been estimated that 1 in 200 young persons suffers from obsessive-compulsive disorder - 3 or 4 students in an average-size elementary school, or up to 20 in a large urban high school (March, Leonard, & Swedo, 1995). Prevalence rates may be even higher, however, since childhood OCD is frequently unrecognized or misdiagnosed (Clarizio, 1991; Rasmussen & Eisen, 1992). Thus, teachers have a critical role to play in the identification, treatment, and management of OCD (Adams & Torchia, 1998).

Over the past decade, a flurry of research in the psychological and medical communities has resulted in rapid and dramatic advances in understanding and treating childhood OCD. This article is essentially a "primer" for classroom practitioners, designed to promote an understanding of OCD and to better equip teachers to assist children who struggle daily with their "OCD monster."

What Is OCD?

Obsessions

The clinical definition of "obsession" refers specifically to thoughts, impulses, urges, or images that seem to force their way into a person's thinking (APA, 1994). Young children may try to explain obsessions in particular ways. They may say, for example, that someone on the outside (e.g., "Jiminy Cricket," "friendly martians") is telling them to do things or is putting thoughts in their heads (Swedo, Rapoport, Leonard, Lenane, & Cheslow,

1989). Most people with OCD, however, are aware that the source of these thoughts is their own minds. Nevertheless, they experience great discomfort, anxiety, and/or fear, because the content of the obsessions often is distressing (APA, 1994).

Common childhood obsessions include fear of contamination; fear of harm, illness, or death; fear of making mistakes that will have disastrous results; magical thinking (i.e., that engaging in certain behavior can prevent something bad from happening); fear of thinking or acting in a way that breaches morality or offends God (commonly called "scrupulosity"); and obsessive thinking related to numbers, symmetry, or sex (Francis & Gragg, 1996; Hanna, 1995; Swedo, Rapoport et al., 1989). Thus, a child may be overwhelmed by worries about germ-infested door handles at school, a house fire that may harm family members, or going to hell because of a sacrilegious thought. Obsessions also may take the form of pathological doubting. Indeed, doubting among OCD sufferers can be so strong that the French have called it "the doubting disease"; individuals doubt their memories or senses to the point that they do not trust their perceptions (Rapoport, 1991).

Most children attempt to ignore or suppress obsessions (March & Leonard, 1996). Without treatment, however, youngsters may be powerless to stop these intrusive thoughts. Having such uncontrollable, disturbing thoughts leads many sufferers to fear that they are going crazy. Individuals with OCD are not crazy, however. In fact, most children have insight into their disorder: They realize that what they are thinking is irrational or, in children's terms, "silly" or "stupid" (Johnston & March, 1992; March & Leonard, 1996).

Compulsions

Whereas obsessions occur only in the mind, compulsions manifest as ritualized behavior that can be either covert (internal, or mental) or overt (outward, or physical). Compulsions are behaviors that are performed intentionally to reduce the anxiety or discomfort brought on by obsessions (APA, 1994). Although a small percentage of sufferers experience only obsessions or only compulsions, the large majority of people with OCD have both obsessions and compulsions (March & Leonard, 1996). Indeed, children frequently experience multiple obsessions and compulsions concurrently. Furthermore, the specific content of their obsessions and compulsions tends to change over time (American Academy of Child and Adolescent Psychiatry [AACAP], 1998).

Compulsions frequently are shaped by the content of the obsession. For children who obsess about germs on a door handle, for example, the corresponding compulsion may take the form of covering their hands before touching the handle, washing their hands immediately after contact with it, or avoiding touching it entirely (Adams & Torchia, 1998). In some cases, however, obsessions and compulsions are paired in a way that cannot be explained. For example, a child may read and reread a sentence over and over again because he believes that doing so will somehow prevent his parents' deaths. The child may not understand his own behavior and may be embarrassed if asked to explain how his repeated actions can influence events (Johnston & March, 1992). It is important to note that some children, particularly younger children, are not aware of, or have difficulty verbalizing, obsessions. In these cases, ritualistic or compulsive behavior may be a more prominent index of OCD (Grados, Labuda, Riddle, & Walkup, 1997).

Common childhood compulsions include excessive handwashing, showering, or cleaning; checking doors, windows, locks, or other objects; repeating actions over and over again; counting; touching or tapping objects; and excessive collecting or hoarding. Mental rituals include saying prayers, words, poems, or songs over and over in one's mind (Hanna, 1995; March & Leonard, 1996; Swedo, Rapoport et al., 1989). Compulsive behavior, then, may manifest in a child's washing his or her hands until they are chapped, cracked, or even bleeding; checking one's body for indications of an illness; or mentally reciting the Lord's Prayer 10 times in a row.

It is important to note that behaviors such as doubting, checking, and repeating represent a normal part of daily functioning. Think for a moment about leaving your home in the morning. You turn the key in the lock. You may think, "Is the door really locked?" Just to be sure, you turn the handle and push on the door. Satisfied that the door is secure, you leave for work. In a similar vein, teachers and children routinely wash their hands at school to promote personal hygiene and prevent the spread of germs and illness. It is only when these actions are carried out to excess - checking the door 20 times or washing one's hands for two hours at a time, for example - that concerns about OCD should be raised. In fact, by definition, an individual has OCD only if the behaviors are distressing and time-consuming, or if they significantly interfere with daily functioning (APA, 1994).

It also is important for teachers to remember that most, if not all, children exhibit developmentally appropriate, normal obsessive-compulsive behaviors. These behaviors occur early in childhood, and actually enhance socialization and advance development. Mastery of separation anxiety, for example, is promoted by bedtime rituals and childhood games such as "step on a crack and you'll break your mother's back." By contrast, OCD occurs somewhat later in development, appears bizarre to adults and other children (if not to the affected child), and produces dysfunction, rather than mastery (Leonard, 1989).

Causes of OCD

While the exact cause or causes of OCD are unclear, substantial evidence suggests that the illness is linked to a disturbance in brain functioning. Much of the research points to a complication in the transmission of serotonin, one of the major chemicals (neurotransmitters) found in the brain (Barr, Goodman, Price, McDougle, & Charney, 1992; Winslow & Insel, 1990). Furthermore, there is evidence to suggest that a particular circuit in the brain is involved in OCD (Swedo, Schapiro et al., 1989). Other research has indicated that the volume of certain structures within the brain may be greater in individuals with OCD than in those without the disorder (Rauch, Bates, & Grachev, 1997).

Other factors that appear to play a role in OCD are genetics, infection, and life events (Lenane et al., 1990). Psychiatric disorders such as depression, Tourette Syndrome, and anxiety disorders other than OCD are common among family members of children with OCD (Lenane et al., 1990). Moreover, research suggests that approximately 25 to 30 percent of children and adolescents with OCD have a parent or sibling with the disorder (Swedo, Leonard, & Rapoport, 1990). Hence, in some cases, there appears to be a genetic predisposition for obsessive-compulsive disorder. Recent research also suggests that for a small percentage of children, sudden-onset OCD or sudden worsening of existing OCD symptoms may result from bacterial or viral infections. According to this theory, antibodies produced to ward off the infections are believed to cause an inflammation in certain areas of the brain, which may result in OCD symptoms (Allen, Leonard, & Swedo, 1995). In addition, the onset of childhood OCD frequently can be linked to a specific, often traumatic, life event such as the death of a loved one, a divorce, a change in schools (e.g., going from elementary school to middle school), a move to a new location, or unhappiness at school (Allsopp & Verduyn, 1990; Rapoport, 1991).

In sum, it is crucial for teachers to realize that neither psychological conflicts nor problems in early childhood, such as inappropriate toilet training, appear to be the root cause of OCD (Greist, 1997; Rapoport, 1991). Thus, although stress from family conflict certainly can affect OCD symptoms, parents do not cause OCD.

Treatment of OCD

Several different treatments have been shown to be beneficial in managing OCD symptoms. A specific form of cognitive behavior therapy known as exposure and response prevention (ERP) has been very effective for many children with OCD (March & Mulle, 1998). Medications that alter the transmission of serotonin in the brain also are used widely to treat OCD, including Anafranil, Prozac, Luvox, Paxil, and Zoloft. Like all medications, such drugs may produce side effects including sedation, insomnia, stomach and intestinal upsets, increased or decreased appetite, and restlessness (Johnston & Fruehling, 1997). Although rare, more serious side effects may occur, including elevated heart rate, dizziness, blackouts, psychiatric symptoms, and seizures. Teachers should notify parents immediately if any of the latter symptoms are observed at school (A. J. Allen, personal communication, June 3, 1997).

Although behavior therapy and medications, alone or in combination, are effective for large numbers of children with OCD, additional treatment components are essential in many cases. Included among these are cognitive therapy, social skills training, support groups, and individual and family therapy (Rapoport, Leonard, Swedo, & Lenane, 1993). For children who struggle with OCD at school, it is very important that educational interventions be a fundamental part of treatment (Adams & Torchia, 1998).

Conditions Associated With OCD

OCD frequently co-exists with other disorders and conditions such as Tourette Syndrome (TS), Attention Deficit/Hyperactivity Disorder (AD/HD), depression, disruptive behavior disorders, and anxiety disorders other than OCD (e.g., panic disorder and separation anxiety) (Hanna, 1995; Swedo, Rapoport et al., 1989). Children with OCD also commonly exhibit a type of learning disability known as a nonverbal learning disability (NVLD). Language and reading skills are intact in children with NVLDs, but they may experience difficulties in nonverbal areas that tap visual-spatial areas. Such difficulties can lead to problems with math, handwriting, and processing social-emotional information (March & Mulle, 1998).

It is essential that teachers recognize another potentially debilitating condition that usually occurs with OCD: family stress. Parents may experience stress as a result of many different factors, including feeling guilty that they may have caused or passed on the disorder; taking a child to numerous physicians, only to receive incorrect diagnoses; and witnessing or feeling pressure to participate in a child's rituals (e.g., the child may insist that a parent repeatedly check a door or wash clothing). In addition, parents frequently have difficulty distinguishing voluntary behavior (behavior that is within the child's control) from involuntary behavior (OCD-related behavior that is outside the child's control) (Adams & Torchia, 1998; A. J. Allen, personal communication, August 22, 1997).

Siblings of children with OCD also may experience significant stress. In some cases, they are ridiculed because of the afflicted sibling's bizarre behavior. They may even be reluctant to invite friends into their homes. Siblings sometimes feel neglected by their parents because it seems as though the affected child "gets all the attention." And indeed, caring for a child with OCD frequently requires an inordinate amount of parents' time and energy. Siblings secretly may be concerned that they, too, will become a victim of OCD. Therefore, when a child suffers from OCD, it is important to attend to the needs of any siblings (Adams & Torchia, 1998; Rapoport, Leonard, Swedo, & Lenane, 1993).

OCD in the School Context

Teachers should be aware that there is a range in the severity level of OCD symptons. For example, a child may have relatively mild symptoms that only minimally interfere with functioning at home or at school. Some children experience symptoms that hinder performance in both settings. Others are adept at keeping their symptoms under control at school. Once at home, however, they frequently "let loose" and begin a frenzy of ritualized, compulsive behavior. This situation may set the stage for conflict between the home and the school: Family members are drained by the child's OCD symptoms, yet school personnel are not observing problems at school. It may even be difficult for school professionals to believe that parents are accurately describing conditions at home. In these circumstances, it is important for teachers to take parents at their word and to provide as much support as possible (Adams & Torchia, 1998).

Symptoms of OCD

Despite differences in the ways OCD manifests at school, some patterns of OCD behavior are recognizable. First and foremost, the teacher must realize that the obsessions that bombard the child will reduce his or her ability to pay attention to instruction (Adams, Waas, March, & Smith, 1994). Thus, the child who frequently has such thoughts as "If I do this wrong, will God be mad at me?" or "If I touch that object, I may get really sick and die" will have difficulty disengaging attention from those thoughts in order to pay attention to the ongoing lesson. The child also may be engaging in mental rituals in response to obsessions. For example, a child may feel compelled to count mentally to 12, 12 times in succession, to prevent her dog from dying. A teacher may observe these children gazing out the window or staring blankly at a worksheet and believe them to be inattentive, lazy, or even defiant, when in fact, the children are trapped in the clutches of OCD. This drain of mental energy may leave little, if any, attention for the task at hand, and frequently diminishes the child's ability to learn. Therefore, work production and grades may suffer (Adams, Waas, March, & Smith, 1994). Children with OCD may become frustrated and embarrassed by their failure to meet teacher and/or parental expectations. If the classroom is an especially threatening environment, they may even take extreme measures to avoid attending school (Clarizio, 1991).

Rituals may remain undetected because many children are skilled at keeping them hidden. The alert teacher, however, may notice one or more of the following warning signs:

* Using a shirt, jacket, glove, paper towel, tissue, etc. to cover hands while touching a door knob or handle

* Making excessive requests to use the bathroom (where the student may be carrying out cleaning rituals)

* Repeatedly checking doors, windows, electrical outlets, classroom media aids, computers, lockers, school supplies, backpacks

* Excessively checking answers on written assignments or tests (parents may report excessive checking of homework assignments)

* Engaging in repetitive movements such as walking in and out of a doorway, getting up and down from a desk, walking up and down the hallway, sharpening a pencil

* Reading and rereading words, sentences, paragraphs, or pages in a book

* Crossing out and rewriting (or erasing and re-erasing) letters, words, numbers, etc. on written assignments (i.e., "perfectionistic" behavior)

* Meticulously filling in circles/boxes on computer-scored answer sheets

* Repeatedly tying shoes so that the bow on each shoe is perfectly balanced

* Arranging items on a desk, shell or worksheet so that they appear symmetrical

* Repeatedly touching an object, such as a tree on the playground

* Avoiding contact with objects such as glue, paste, paint, clay, chalk, or scissors 

* Repeatedly asking questions to secure reassurance (e.g., about safety concerns)

* Showing signs of fatigue (the child may be staying up late completing rituals)

* Being habitually tardy (the child may be engaging in morning rituals). (Adams & Torchia, 1998)

OCD also may have a significant effect on social functioning. Children with OCD frequently have difficulty making and maintaining friendships. Aware that their thoughts and behaviors are odd and socially unacceptable, these young people may go to great lengths to hide the disorder from their peers, resulting in social isolation. Furthermore, preoccupation with unending obsessions and rituals frequently leaves little time or energy for friends or family. When OCD symptoms are observable to peers, the child may become the target of teasing and cruel remarks, encouraging further social ostracism (Clarizio, 1991; Rapoport, Leonard, Swedo, & Lenane, 1993).

How Teachers Can Help

P-8 teachers can play a pivotal role in the life of a child with OCD in several ways. First, they must become educated about the disorder and its various manifestations in the school setting. Adams, Waas, March, and Smith (1994) stress that,

Classroom teachers represent a crucial resource in the identification process due to their extensive interaction with, and opportunities to observe, students. Teachers are also in a position to receive verbal reports from other students concerning a child exhibiting OCD-related behaviors. For these reasons, the initial identification of children at risk for OCD often will be made by classroom teachers. (p. 280, italics added)

Second, the teacher can collaborate with student services personnel (e.g., school psychologist, counselor, social worker) to explore options for an outside mental health evaluation. Third, once a diagnosis of OCD has been made, the teacher can play an important role in school-based academic and behavioral interventions. Teachers also can monitor and document the effects of medication and share their observations with health care providers (Adams & Torchia, 1998).

Educational Services for Youth With OCD

Most students with OCD can succeed in the general education classroom setting (Johnston & Fruehling, 1997). In some cases, teachers will need to make specific accommodations or modifications. For example, a student with OCD who has trouble with written assignments due to writing compulsions (e.g., the child endlessly writes and rewrites words) may need to do assignments orally or put responses on tape. (The interested reader is referred to Adams & Torchia, 1998, for a more complete discussion of accommodations.) Such accommodations may be provided within the context of a "504 plan" (Adams & Torchia, 1998). Section 504 of the Rehabilitation Act of 1973, a civil rights law, states that a child qualifies for special services if he or she exhibits a physical or mental impairment that substantially limits one or more major life activities, such as caring for oneself, learning, or working. Students with more serious cases of OCD may require special education and related services under the Individuals With Disabilities Education Act (IDEA) (Johnston & Fruehling, 1997). Under this law, students with OCD may be eligible for services under the category of "Other Health Impaired." It is essential that classroom teachers be familiar with these and other federal and state laws that protect the rights of students with disabilities such as OCD to a free, appropriate, public education.

Conclusion

Obsessive-compulsive disorder is a serious and potentially debilitating illness. You can make a profound difference in the lives of these students by taking a deeper look at their behavior and, if you suspect OCD, taking appropriate steps. Darren Fleeger (1995) wishes that a teacher had done that for him:

As a child with OCD, I was very sensitive, moody, depressed, and introverted. Much of my time was spent seeking refuge in some solitary activity.... Teachers saw me as a bright, though emotional, student. Now I wish that my character was more problematic in school. OCD is such a secretive and embarrassing disease. It would have been nice if someone had picked up on my strange behavior and suggested something. Maybe that would have saved [me] years of suffering. (pp. 27-28)

References

Adams, G. B., & Torchia, M. (1998). School personnel: A critical link in the identification, treatment, and management of OCD in children and adolescents. Milford, CT: OC Foundation.

Adams, G. B., Waas, G. A., March, J. S., & Smith, M. C. (1994). Obsessive compulsive disorder in children and adolescents: The role of the school psychologist in identification, assessment, and treatment. School Psychology Quarterly, 9(4), 274-294.

Allen, A. J., Leonard, H. L., & Swedo, S. E. (1995). Case study: A new infection-triggered, autoimmune subtype of pediatric OCD and Tourette's Syndrome. Journal of the American Academy of Child and Adolescent Psychiatry, 34(3), 307-311.

Allsopp, M., & Verduyn, C. (1990). Adolescents with obsessive-compulsive disorder: A case note review of consecutive patients referred to a provincial regional adolescent psychiatry unit. Journal of Adolescence, 13(2), 157-169.

American Academy of Child and Adolescent Psychiatry. (1998). 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, 37(10) (supplement), 27S-45S.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

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Johnston, H. F., & Fruehling, J. J. (1997). Obsessive compulsive disorder in children and adolescents: A guide. Madison, WI: Child Psychopharmacology Information Service.

Johnston, H. F., & March, J. S. (1992). Obsessive-compulsive disorder in children and adolescents. In W. M. Reynolds (Ed.), Internalizing disorders in children and adolescents (pp. 107-148). New York: John Wiley & Sons.

Lenane, M. C., Swedo, S. E., Leonard, H. L., Pauls, D. L., Sceery, W., & Rapoport, J. L. (1990). Psychiatric disorders in first degree relatives of children and adolescents with obsessive compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 29(3), 407-412.

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March, J. S., & Leonard, H. L. (1996). Obsessive-compulsive disorder in children and adolescents: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 34(10), 1265-1273.

March, J. S., Leonard, H. L., & Swedo, S. E. (1995). Pharmacotherapy of obsessive-compulsive disorder. Pediatric Psychopharmacology, 4(1), 217-236.

March, J. S., & Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual. New York: The Guilford Press.

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Rasmussen, S. A., & Eisen, J. L. (1992). The epidemiology and differential diagnosis of obsessive compulsive disorder. Journal of Clinical Psychiatry, 53(4) (supplement), 4-10.

Rauch, S. L., Bates, J. F., & Grachev, I.D. (1997). Obsessive-compulsive disorder. Child and Adolescent Psychiatric Clinics of North America, 6(2), 365-381.

Swedo, S. E., Leonard, H. L., & Rapoport, J. L. (1990). Childhood-onset obsessive compulsive disorder. In M. A. Jenike, L. Baer, & W. E. Minichiello (Eds.), Obsessive-compulsive disorders: Theory and management (pp. 28-38). Littleton, MA: PSG.

Swedo, S. E., Rapoport, J. L., Leonard, H., Lenane, M., & Cheslow, D. (1989). Obsessive-compulsive disorder in children and adolescents. Archives of General Psychiatry, 46, 335-341.

Swedo, S. E., Schapiro, M. B., Grady, C. L., Cheslow, D. L., Leonard, H. L., Kumar, A., Friedland, R., Rapoport, S. I., & Rapoport, J. L. (1989). Cerebral glucose metabolism in childhood-onset obsessive-compulsive disorder. Archives of General Psychiatry, 46, 518-523.

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Resource Address

For information on OCD, contact the Obsessive-Compulsive Foundation, P.O. Box 70, Milford, CT 06460; 203-878-5669; http://www.ocfoundation.org.

Gail B. Adams is Educational Psychologist, Department of Pediatrics, University of Illinois, Chicago Medical Center.

Robert W. Burke is Assistant Professor, Department of Elementary Education, Ball State University, Muncie, indiana.