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Children and Teens with Obsessive Compulsive Disorder
© 2005 by Instant Help Publications
About Instant Help Charts
This chart is intended to provide a
summary of the critical information
available on helping children with OCD
to insure that every child gets the
most appropriate and comprehensive
consideration.
Defining the Problem
According to the American Psychiatric Association
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, (DSM-IV) obsessive
compulsive disorder (OCD) is an anxiety disorder
characterized by recurrent obsessions or compul-
Assessing OCD
sions that are severe enough to be time consuming
simply excessive worries about real-life problems. Obsessive behaviors included in the definition
There are no laboratory tests to
determine the presence of OCD.
Therefore, a number of sources are
used in the basic assessment of a
child’s symptoms. Assessment should
minimally include:
are repeated thoughts about contamination, doubts, a need to have things in a particular order,
z Direct observation of the child
aggressive or horrific impulses, and sexual imagery. Compulsions are defined as repetitive
z Interviews with the child, parents,
(more than one hour per day), cause distress, or interfere with a child’s normal routine, academic
functioning, social activities or relationships. Obsessions are defined as persistent ideas,
thoughts, impulses, or images that are experienced as intrusive and inappropriate; they are not
behaviors or mental acts, the goal of which is to prevent or reduce anxiety or stress rather than
to provide pleasure or gratification. Compulsions included in the definition are hand washing,
ordering, checking, praying, counting, or repeating words silently. OCD usually involves both
obsessions and compulsions, but it is possible for a child with OCD to have one or the other.
(continued on p. 2)
Counseling Children and
Teens with OCD
The most effective treatment for children and
teens with OCD appears to be exposure and
response prevention (E/RP) with cognitive
behavioral therapy (CBT). Children learn to
change their thoughts and behaviors through
repeated exposure to anxiety-provoking stimuli.
Goals in Developing a Treatment Plan
z To reduce obsessive thoughts and
compulsive behaviors
z To develop methods to keep symptoms
from affecting school and social
functioning
z To assimilate isolated children by
teaching them prosocial skills
z To teach family members how to slowly
stop participating in the child’s OCDrelated rituals without causing anxiety in
the child
CBT is usually implemented in 13–20 weekly
individual or family sessions, depending on
the child’s age. The therapist and child work
together to determine the child’s comfort level
and ability to participate in anxiety-provoking
situations. In addition to practicing newly
acquired skills in the therapist’s office,
children are given “homework” so they can
practice new skills in real-life situations. A new
treatment plan is developed each week based
on the child’s improvement.
Specific skills are taught through:
z Gradual exposure to OCD-provoking
situations
z Self-talk exercises that intentionally
elicit obsessive thoughts while refraining
from acting on the resulting compulsive
response
z Relaxation techniques
z Self-administered positive reinforcement
z Modeling and shaping the desired behavior
and teachers
z Review of school records and
reports
z Verbal reports from classmates
and friends
A more thorough assessment might
also include:
z Structured interviews with the child
z Intelligence and achievement
testing to determine the need of
special education services
z Mental status examination
Commonly used assessment tools
include:
z Clark-Beck Obsessive Compulsive
Inventory, Harcourt
z Children’s Yale-Brown Obsessive-
Compulsive Scale, Plenum
z Maudsley Obsessive-Compulsive
Inventory, Plenum
z State Trait Anxiety Inventory I and II,
Consulting Psychologists Press
z Beck’s Depression Inventory,
Basis-32, Psychological Corporation
z Beck Anxiety Inventory, Harcourt
z Fear of Negative Evaluation
Survey, Lexi-Comp
A complete evaluation should gather
information from multiple sources.
Defining the Problem (continued)
The signs and symptoms of OCD vary in
both type and severity among children and
can begin as early as age two. Younger children may not recognize that their beliefs or
actions are illogical; those who do are often
secretive about their symptoms. For this
reason, OCD often goes unrecognized and
therefore undiagnosed. Without treatment,
OCD is usually a lifelong problem with symptoms improving and worsening periodically.
It is estimated that at least one-third of
children with one anxiety disorder meet the
criteria for two or more anxiety disorders.
Conditions usually comorbid with OCD
include other anxiety disorders, depression,
disruptive behavior disorders, learning
disorders, tic disorders, trichotillomania, and
body dysmorphic disorder.
OCD symptoms occurs after a stressful
event; for example, the remarriage of a
parent or death of a relative or friend.
z The incidence of the disorder is higher
z Fear of contamination is thought to be
among first-degree relatives of children
the most frequent obsession associated
with OCD, particularly fathers. However,
with OCD. An overly exaggerated
children who develop OCD generally
awareness of germs, disease, or dirt
experience different symptoms from
results in compulsions performed to
those experienced by family members.
reduce the existence of these “feared”
For example, a child with OCD may be
contaminants. Excessive hand washing
obsessive about germs and compuland cleaning are commonly associated
sively wash his hands. The child’s
escape compulsions. Other common
father may be obsessive about order
compulsions are counting, checking,
and compulsively arrange the garage.
and hoarding; these are usually related
z Estimates suggest that OCD occurs in
to obsessions involving moral doubts,
approximately 1 in 100 children and
loss of control and order, respectively.
equally affects both males and females. z Children with OCD may experience
z Some cases of OCD may be associated
stress-related symptoms, such as
with streptococcus infection in children.
headaches and upset stomachs. These
These cases, referred to as Pediatric
may be related to inadequate sleep or
Autoimmune Neuropsychiatric
poor nutrition resulting from the time
Disorders Associated with Streptococcal
and effort needed to perform
Infections (PANDAS), are characterized
compulsive rituals.
by an abrupt onset of OCD symptoms
z Most children with OCD experience
after a strep infection. Antibiotics may
pathological doubts, such as “If I don’t
be helpful.
do this, something bad will happen (to
z In about 50% to 70% of cases, onset of
me, my family, etc.).”
Fast Facts
What Parents Need to Know
Because OCD tends to get worse without treatment, it gradually disrupts a child’s behavior
more and more. Hiding these behaviors becomes complex and stressful, and they may only
become apparent long after the child first began experiencing the signs of OCD. Although
families do not actually cause OCD, family members’ reactions to the disorder affect the
symptoms. Factors within the family dynamics that can intensify OCD behaviors include a
recent family move, divorce, new stepparent or stepsiblings, changes in school, death of a
family 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 control
compulsive 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 focus
on 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 eliminate
unnecessary sources of stress in the child’s home and outside environment and be willing to make changes in the family lifestyle to
accommodate 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 of
communication with their children that does not involve criticism or punishment for OCD behaviors.
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The Dos and Don’ts of Communicating
DON’T
DO
• Make negative comments about OCD-related
• Offer calm, understanding support.
• Learn as much as you can about the disorder and
behaviors.
• Ignore the signs and symptoms of OCD.
• Refuse to participate in the symptoms.
• Criticize thoughts or actions associated with the
child’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.
discuss it with the child.
• Work with the child in developing a strategy to disengage 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.
What Teachers Need to Know
Teachers are often the first to become aware of a child’s or teen’s compulsive behavior but may
misattribute the child’s actions to laziness or stubbornness. Refusal to attend school, repeated tardiness, poor concentration, excessive focus on having belongings neat and tidy, frequent trips to the
bathroom, 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 may
exhibit signs of OCD in the classroom. With an understanding of OCD, teachers can help children
find effective ways of managing their maladaptive behaviors, without adding undue pressure that
could make the symptoms worse. Accommodating the behaviors related to OCD is essential. Here
are some ways that teachers can assist children with OCD:
z Reducing triggers of compulsive rituals
Situations that provoke anxiety, such as unclear expectations, complex assignments, or changes in schedule,are likely to trigger
compulsive rituals. Giving the student clear explanations, making assignment modifications, and providing advanced notification of
changes in the regular class routine are accommodations that can help the student with OCD.
z Time management
Teachers should allow adequate time for completing tasks, assignments, and tests. Make a contract with the student detailing what is
acceptable: how much time is allotted to complete the assignment; how much rewriting is permissible; and whether in-class assignments
may be completed at home.
z Communication with the OCD student
Teachers should frequently talk with the student determine what support or assistance might be needed. Develop strategies for dealing
with negative social situations or confrontations.
z Redirection
Rather than using punishment, a system for redirecting the student’s behavior should be implemented.
z Development of a support system
Designate a mentor within the school system who understands OCD and can be available for the student to regularly talk with.
z Educating classmates
Conduct a peer education programs, designate a “study buddy,” and structure class activities so that students with OCD who have trouble
with 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 the
student. Work with the child and the family to help reduce OCD symptoms by using suggested treatment plans. If the disorder significantly
interferes with learning or behavior, children with OCD may qualify for special education services.
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Instant Help for Children and Teens with Obsessive Compulsive Disorder • 3
This Instant Help Chart was written by
Leslie Burling-Phillips
Instant Help for
Children and Teens with
Obsessive Compulsive Disorder
Published by
Instant Help Publications
4 Berkeley Street
Norwalk, CT 06850
www.InstantHelpBooks.com
Medication and OCD
Medication Protocol
Treatment with medication should be
considered when a child is experiencing
significant OCD-related impairment or
distress and when CBT is not successful or is
only partially effective. A frequent and
ongoing evaluation of the child is necessary
to plan, modify, and monitor treatment.
Important steps include:
z Assessment of symptom severity.
z Review of the success of CBT.
z Physical and psychiatric evaluation.
Laboratory tests are necessary before
and during treatment with Anafranil but
not with other SSRIs, particularly for children with preexisting heart disease.
z Consideration of how medication will be
supervised at home and school.
z Review of possible side effects. Research
indicates that all SSRIs are equally
effective in the treatment of OCD and
have similar side effects that include
nervousness, insomnia, restlessness,
nausea, and diarrhea.
z The implementation of a monitoring
schedule that will collect data on both
therapeutic benefits and side effects.
Weekly appointments are usually
necessary at the beginning of treatment
to develop a treatment plan and to
monitor symptoms, medication doses,
and side effects. Once an optimal treatment schedule is established, monthly
follow-up visits are recommended for at
least six months and continued treatment
for at least one year before attempting to
discontinue medication or CBT.
z Counseling the child and parents about
the medication, possible side effects,
interactions, and adverse withdrawal
effects.
Research shows that
selective serotonin reuptake
inhibitors (SSRIs) can be an
effective treatment for
OCD. These medications increase
and regulate the
level of serotonin
in the brain.
However, when
medication is
discontinued, symptoms usually return
to the predrug level of severity. In
October 2004, the Food and Drug
Administration warned that use of antidepressant drugs, including SSRIs, may
increase the risk of suicidal ideation and
suicidal behavior in a small number of
children and adolescents.
Examples of commonly prescribed
SSRIs include:
z Anafranil
z Prozac
z Luvox
z Paxil
z Zoloft
z Celexa
Occasionally, when SSRIs prove ineffective, the monoamine oxidase inhibitor
(MAOI), Nardil, may be prescribed. It
usually takes from two to three months
of medication treatment to see significant improvements in OCD symptoms.
The success rate of medication alone in
the treatment of OCD is less than 20%.
For this reason, medication is almost
always combined with CBT to achieve
optimal results.
The Brain and OCD
Although the precise neuropsychological causes of OCD are
unknown, research indicates that there is increased activity
in the frontal lobes, basal ganglia, and cingulum of the
OCD-affected brain. These brain structures use the
chemical messenger serotonin for communication. It is
believed that abnormal levels of serotonin are involved in OCD.
Resources for Helping Children and Teens with OCD
Books for Parents
Obsessive Compulsive Disorder: New Help
for the Family. Herbert L. Gravitz, Partners
Publishers Group, 2004
Worried No More: Help and Hope for
Anxious Children. Aureen Pinto Wagner,
Lighthouse Press, 2005
Freeing Your Child from ObsessiveCompulsive Disorder: A Powerful, Practical
Program for Parents of Children and
Adolescents. Tamar E. Chansky, Three
Rivers Press, 2001
What to Do When Your Child Has
Obsessive-Compulsive Disorder: Strategies
and Solutions. Aureen Pinto Wagner,
Lighthouse Press, 2002
Helping Your Child with OCD: A Workbook
for Parents of Children with ObsessiveCompulsive Disorder. Lee Fitzgibbons and
Cherry Pedrick, New Harbinger, 2003
Wagner and Paul A. Jutton, Lighthouse
Press, 2004
A Thought Is Just a Thought: A Story of
Living with OCD. Leslie Talley, Lantern
Books, 2004
Mr. Worry: A Story about OCD. Holly L.
Niner and Greg Swearingen, Albert
Whitman and Company, 2004
Books for Children and Teens
Up and Down the Worry Hill: A Children’s
Book about Obsessive-Compulsive
Disorder and Its Treatment. Aureen Pinto
Books for Professionals
Obsessive Compulsive Disorder: Theory,
Research, and Treatment. Richard P.
Swinson,et al (Eds.), Guilford Press, 2001
4 • Instant Help for Children and Teens with Obsessive Compulsive Disorder
Treatment of Obsessive Compulsive
Disorders. G. Steketee, Guilford Press, 1996
Cognitive Therapy for ObsessiveCompulsive Disorder: A Guide for
Professionals. Aaron T. Beck, New
Harbinger, 2006 release
Cognitive-Behavioral Therapy for OCD.
David A. Clark, Guilford Press, 2003
OCD in Children and Adolescents: A
Cognitive-Behavioral Treatment Manual.
John S. March, Karen Mulle, Guilford
Press, 1998
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