Sunday, May 3rd to Saturday, May 9th is “Children’s Mental Health Awareness Week,” a national effort to raise awareness about the mental health needs of America’s youth. With obsessive compulsive disorder (OCD) affecting an estimated 2.2 million American adults, the condition first surfaces during childhood or early adolescence. To learn more about OCD, we spoke with expert Judy Rapoport, M.D., who is chief of the child psychiatry branch at the National Institute of Mental Health and a Dana Alliance member.
It’s not uncommon to hear someone casually say they “have OCD” because they like to keep things organized in a certain way or follow some sort of ritual every day. What is the real distinction between someone who is particular and someone who is diagnosed with OCD?
People diagnosed with OCD have habits or thoughts that significantly interfere with their functioning. For example, one patient may spend so much time, carrying out some other ritual that they are unable to go to work. Others are so preoccupied that they have an illness or that they have hurt someone that they can think or talk about little else. This is an important question, however, because there is a “dimension” of OCD, and there are some people whose habits are on the borderline of a disorder but they, and those around them, can manage with them.
About half of all patients diagnosed with OCD are below the age of fifteen. As a condition that surfaces during childhood or adolescence, what are some early behavioral signs that a child with OCD might exhibit?
We have seen clear cases as early as age four. One small boy would circle manhole covers. When he got to kindergarten, he constantly drew circles. Often young children will have washing compulsions or a preoccupation with putting their toys in a certain order. We have followed many such children into their adult years, and while the specific symptoms may change, typically the OCD remains.
Do we know what causes OCD?
We have many hints, but there is no simple answer. There is good evidence from family and twin studies that OCD is quite heritable. However, no genes of strong effect have been found. There are studies suggesting that certain brain circuits between the frontal lobes and the basal ganglia (parts of the brain involved in planning complex behaviors) are abnormal in OCD, but this is a research finding without immediate clinical use. A small number of children may have OCD in response to a bacterial or even viral infection, but this is still under study. What does seem clear is that OCD is not a product of poor parenting. Intriguingly, in children, OCD may be seen together with motor tics or Tourette’s syndrome. We also know that OCD has some relationship with a hair pulling disorder (called Tricotillomania). All of these abnormalities show abnormalities of brain circuitry, but that does not indicate any clear cause.
Is there a form of treatment that has shown to be more effective than others? Can you elaborate on some of your research regarding treatment for OCD?
It is clearly established that both medications in a class called serotonin reuptake inhibitors (SRIs) and cognitive behavior therapy are effective. In many more severe cases there is a clear advantage to starting both therapies together. We were the first to treat children with OCD using clomipramine, the first of the SRIs to be shown effective. There are now six others in use. For behavior therapy, the most effective part is called “Exposure with Response Prevention” (ERP). In ERP, the child must be exposed to something triggering a ritual (for example, get their hands dirty and prevent the usual response by not washing their hands for a prolonged period of time). When hand washing is restricted daily for several weeks, this approach proves to be an important mainstay of treatment. Each of these two treatments has advantages, and it is hard to judge one better than the other.
To learn more about obsessive compulsive disorder and what goes on in the adolescent brain, check out the National Institute of Mental Health’s website.