Twelve-year-old Max hadn't attended school in three months. In fact, he was barely able to leave his house. He spent so many hours each day washing his hands that they were cracked and bleeding. And because he believed his two siblings are contaminated, he refused to be in the same room with them. If his mother cooked dinner for him and one of his siblings walked by the stove, he'd believe the food got contaminated, so she'd re-cook it.
Max has obsessive-compulsive disorder, an anxiety disorder that affects 3 percent of children. The condition usually strikes boys between ages 6 and 12 and girls between 7 and 11. About 1 in 200 kids or 500,000 (and 1 in 100 or between 2 and 3 million adults) has OCD. "That means that in a typical elementary school, there are eight to ten kids -- and a bunch of staff members -- with OCD," says Jerry Bubrick, Ph.D., a psychologist who is the senior director of the Child Mind Institute's Anxiety & Mood Disorders Center in New York City and specializes in the treatment of OCD.
"It usually starts with occasional symptoms," says Dr. Bubrick. "Parents think their kids will grow out of it, and then they see that it progressively worsens over months or years." Kids with OCD experience symptoms for at least one hour a day and often much more.
As the name suggests, the disorder consists of two components: obsessions and compulsions.
But the obsession and compulsion are not always related in an obvious way: A child might think that if he doesn't always begin walking with his right foot, for example, someone he loves might die. Other common compulsions (also called rituals) include tapping an object or a body part. A child may think, "I have to tap my leg four times, and if I get interrupted, I have to start over again." He may feel compelled to shower or brush his teeth frequently. When eating food, he may chew four times on the right side, then four times on the left. "There are different patterns that kids will feel compelled to do until they feel 'right,'" says Dr. Bubrick.
Children often feel shame and embarrassment about their OCD and will try to hide their compulsions from other people. If the child's parents notice the behavior (which most parents do eventually) and ask him what he's doing, he will most likely say, "I don't know" -- which is the truth. "Parents want to understand what their child is doing and why," explains Dr. Bubrick, "but the child may not know why he's doing it other than that he doesn't feel right unless he does." It's very difficult for a child with OCD to just stop his compulsions.
"Kids have OCD because of how their brain is wired," says Dr. Bubrick. Researchers believe insufficient levels of a neurotransmitter called serotonin may be a factor.
There is also a genetic component to OCD -- if a biological parent has OCD, there's a 4 percent to 8 percent chance he or she will pass it on to a child. Having a family member with another type of anxiety disorder, such as social anxiety disorder or a phobia, can also increase the risk.
And while stress doesn't cause OCD, it can worsen symptoms. "Stress and OCD are best friends," says Dr. Bubrick. "The more stressed out a child is, whether from school tests or a traumatic family event, the easier it is to give in to the obsessions and the more obsessions he's going to have to fight."
In rare cases, OCD can develop quickly and with severe symptoms, a condition known as pediatric acute-onset neuropsychiatric syndrome, or PANS. This can be the result of strep throat or other infections, such as Lyme disease and mononucleosis. (It was formerly known as PANDAS, for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections; the new name was designed to create a broader category of OCD that isn't directly linked to strep.)
Mild to moderate cases of OCD are typically treated with cognitive behavioral therapy (CBT). More severe cases may require a combination of CBT and medication (such as selective serotonin reuptake inhibitors, or SSRIs). If a strep infection is the cause, it will be treated with antibiotics.
During CBT, the whole family gets involved, with the child and his parents and siblings learning to understand what OCD is and how to manage it. "We teach kids how to face their fears head on and cope with the anxiety that comes with it," says Dr. Bubrick. "We give them a toolbox of skills they can use for a lifetime."
One crucial component of treatment is what's called "exposure with response prevention." As Dr. Bubrick explains, "If you jump into a swimming pool and the water is chilly, you stay in the water a little bit and your body gets used to it." Anxiety works the same way. "We systematically, in a structured way and at the child's pace, expose him to his fears without letting him do his rituals. After a period of time, there's no need for the ritual anymore." For example, a child who fears germs may be asked to touch a doorknob without immediately washing his hands. The more times he does this, the less afraid and anxious he is and the less compelled he feels to wash his hands. "We can see marked improvement within five to seven sessions, and usually after 12 to 15, we see up to an 80 percent improvement," says Dr. Bubrick. If symptoms re-emerge in the future, as they sometimes do during stressful times, that same toolbox of coping strategies can be used.
CBT worked well for Max, the boy with OCD who thought his siblings were contaminated. Within three weeks, he was hugging his siblings and eating dinner with them, and in less than two months, he was back to school full-time. "There is no cure," says Dr. Bubrick, "but what we have is a really effective treatment."
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