STEP ON A CRACK,
BREAK YOUR MOTHER’S BACK
When I was in junior high school, a boy from my homeroom used to fascinate me in the school cafeteria every day. Like the rest of us, Norman would stand in line, fill his tray with food, and carry it back to the table. That’s when it got interesting. I would stare, mesmerized, as Norman proceeded to eat his lunch one quadrant at a time. He was incredibly precise about it; first he’d eat what was directly in front of him. Then he’d carefully rotate the plate 90 degrees and eat the contents of the second quarter. He went on like this until his plate was clean. Kids teased him about it, of course, but during the time I knew him he didn’t change his eating habits. Back then I thought Norman was weird. Today I’m reasonably sure that he had obsessive compulsive disorder, or OCD.
Childhood rituals and superstitions are perfectly normal. At about two and a half years of age children begin to follow and indeed expect a regular routine, especially at mealtimes or in preparation for bed. “Before I go to bed, I brush my teeth. Then Daddy reads me a story, and Mommy rubs my back,” a child might recite. Another kid says: “When I take a bath, I have six toys in the tub with me. Daddy sings Rubber Ducky’ while he washes my hair.” Any change in routine can create discomfort in a small child. Between five and six children develop group rituals, during which they play games. These games nearly always have rules, and most kids are as strict as Marine drill sergeants about them. Anyone who tries to circumvent or break the rules will face an extremely irate kindergartner. As children get older—from seven to 11 or so—they begin to take up hobbies and start collections: stamps, coins, baseball cards, dolls, and so on. They often appear overly preoccupied with their hobbies, but that too is normal. Obsessiveness is part of any hobby or collection.
Ritualized behavior helps to relieve anxiety and eases socialization in children as well as in adults. Anyone who has ever worn a “lucky shirt” to watch the World Series on television or knocked on wood to ward off bad luck knows about the stability that pointless rituals can bring. At any age we derive comfort from following a routine, waking up, going to school or work, eating meals, going to bed for the night. Some people are more obsessive-compulsive about their actions than others, like the man who checks his keys half a dozen times or the woman who has to lock the front door exactly three times before she can leave the house. “Checking” is a common behavior: locks, lights, ovens, faucets. It often verges on obsessive-compulsive, but if it doesn’t interfere with functioning, it isn’t considered a symptom of the disorder. When obsessive thoughts and compulsive acts become so frequent or so intense that they cause distress or dysfunction, a diagnosis of obsessive compulsive disorder is made.
Two eight-year-old girls are skipping down the street, and bystanders can hear their familiar refrain: “Step on a crack, break your mother’s back.” Both are avoiding the cracks in the sidewalk, but one little girl loses interest after covering less than a block. The other keeps going, refuses to stop. When the second little girl is asked why, she seems distressed. “I can’t stop because I haven’t done it enough times,” she says, and keeps on skipping. There’s nothing carefree or cheerful about her actions. She’s an eight-year-old with a mission. The first little girl is playing a simple fantasy game. The second child has OCD.
THE SYMPTOMS
Obsessive compulsive disorder is an anxiety disorder characterized by pathological obsessions (involuntary thoughts, ideas, urges, impulses, or worries that run through a person’s mind repeatedly) and compulsions (purposeless repetitive behaviors). OCD affects as many as 3 percent of the general population, roughly 1 million of whom are children and adolescents. That translates into three or five youngsters with OCD per average-sized elementary school and as many as twenty in a large urban high school. The onset of OCD may be as early as preschool—age three or four—with a peak onset at age 10. Adults with OCD almost certainly had the disorder as children or adolescents; research has revealed that more than 50 percent of the adults with this disorder had symptoms before age 15. More boys have OCD than girls. Other anxiety disorders are more common in females, but with OCD the ratio of boys to girls is 2 to 1.
OCD has a wide range of symptoms, from seemingly benign to obviously bizarre. (Every time I think I’ve seen everything, a child will show up with a new wrinkle.) Many children become obsessed about precision, demanding that things be done a certain way or, quite often, that questions be answered over and over again. Other common obsessions are germs, lucky or unlucky numbers, religion, and bodily functions. Some of the most common compulsions are hand-washing, touching, counting, and hoarding.
Some kids have violent temper outbursts if their rituals are blocked or their questions don’t receive the proper responses. Nine-year-old Manuel had a long history of temper tantrums. When I asked his parents what was likely to set Manuel off, they gave me a succinct answer: “Anything.” When I asked them to be more specific, I learned that what made Manuel lose his temper was not typical. “What time is dinner?” he would ask. “In a couple of hours,” Mom would answer. “No. When is dinner?” he repeated. Only when his parents were specific to the minute was Manuel satisfied, and even then he needed to hear the answer many times before he could feel reassured.
In the first few moments of my meeting with Manuel I got firsthand confirmation of his parents’ reports. I asked Manuel to get on the scale so that I could weigh him. “How much do I weigh?” he inquired. I told him. “Is that the right weight for me?” he asked. I said, “Well, we have a range of weights, and yes, you’re in the right category.” “But is that really the right weight? Is it exactly the right weight?” he asked. I could sense his anxiety. It all but overwhelmed him. “This is exactly the right weight for you,” I told him. He calmed down almost immediately.
Taking his first ride on an airplane, Stuart, age 10, kept peppering the flight attendant with questions.
“What kind of plane is this?”
“This is a 727,” she answered.
“Is this the safest type of plane?”
“Yes, it’s very safe.”
“But is it the safest plane?”
“All of our planes are safe.”
“But is this the safest plane?”
When the stewardess didn’t answer Stuart’s question for the third time, he became extremely agitated. “Is this the safest plane?” he repeated. “If you don’t answer me, I’m going to kill you.”
At this point Stuart was shouting and waving his arms around, and his nervous parents began to reassure him, telling him that yes, their plane was indeed the safest. The flight attendant had the presence of mind to agree that the plane they were flying in was absolutely the safest in the skies. Stuart’s tantrum subsided.
Outbursts of temper don’t always end in a truce. OCD has been known to lead to violence. An adolescent girl with an obsession about tearing and breaking things nearly flattened the OCD unit in a midwestern hospital last year. Before being restrained she had shredded the curtains, shattered the windows, and completely destroyed three sinks.
Anyone familiar with Judith Rapoport’s important 1989 book about OCD, The Boy Who Couldn’t Stop Washing, knows that one of the most common symptoms associated with OCD is an obsession with cleanliness and fear of contamination, often manifested by the constant washing of hands or compulsive wiping after using the toilet. Lately my colleagues and I have been seeing a new, related obsession connected to OCD: fear of AIDS. As many as half the people diagnosed with OCD who come through our hospital are overly (and illogically) concerned about the virus. I especially remember a 14-year-old girl who had persuaded herself that she was dying of AIDS. Six months earlier she had been walking on the beach and had stepped on something sharp. Convinced that the pointed object was a contaminated needle, she had been washing her foot 50 times a day ever since, until it was raw and bleeding. I’ve seen other youngsters with OCD who call AIDS hotlines 50 times a day.
There is no relationship between O
CD and IQ. Jake was an extremely bright kid with a high IQ, who eventually became class valedictorian. In fact, Jake’s anxieties had to do with his intelligence; he was obsessed with the idea that he was becoming stupid, that he was literally losing his intelligence. “My brain cells are dying,” he told me, sobbing. To keep this from happening Jake had developed a series of rituals that only he knew about: opening his locker while standing on one foot, putting his socks on before his underwear, touching the four corners of a room before leaving, and at least a half-dozen others. Jake was 16 when his parents brought him to see me, because he had had a problem taking his SATs. He wrote his answer, erased it, wrote it again, and erased it again, so that he finished only a quarter of the test. His parents knew that there was something very wrong. What they didn’t realize was that Jake had been having similar problems since the age of 10. It’s not unusual for parents to be kept in the dark about OCD. Many children, realizing that their symptoms make no sense and feeling a sense of shame about them, keep their symptoms secret.
THE DIAGNOSIS
There is no biological test for OCD. The diagnosis of OCD in children and adolescents requires a systematic, comprehensive evaluation. That means questions, questions, and more questions. If the child is eight years or older and the therapist suspects OCD, he’ll probably begin by filling out the Yale Brown Obsessive-Compulsive Scale and the Leyton Obsessional Inventory, tests that measure not just the presence or absence of obsessive thoughts and compulsive behaviors but also dysfunction and the degree to which a youngster tries to resist his symptoms. There are 20 items in the Leyton form, including: Do you have to check things several times? Do thoughts or words keep going over and over in your mind? Do you hate dirt and dirty things? Do you get angry if other students mess up your desk? Do you ever have trouble finishing your schoolwork or chores because you have to do something over and over again? Do you move or talk in a special way to avoid bad luck?
The interviewing process with a child with OCD is often an uphill battle, with a slow pace and a great deal of reassurance on the part of the therapist. A child has to be made to feel safe and secure; he has to be persuaded that the secret thoughts he has and the secret things he does are nothing to be ashamed of. “I am not going to be surprised by anything you say,” I might tell a child. “Tell me about the silly things you do. I’ll understand. I’ve talked to lots of kids who have the same problem as yours. I’m going to try to make it better.”
Some children are unwilling to acknowledge that anything is wrong. I’ve met kids who try to explain away their peculiar habits as a matter of “lifestyle.” “Sure, I wash my hands 50 times a day and I use a whole tube of toothpaste to brush my teeth, but that’s just me. That’s the way I like it.” Others are terrified that they’re going crazy. Still others know that there’s something wrong with them, but they’re too embarrassed to talk about it. The word “silly” comes up a lot, as in “I do a lot of silly things.” There’s a lot of shame associated with OCD. One boy I treated was caught “cheating” in class. His teacher noticed that he was turning his head from side to side during a spelling test, and, little knowing that the boy had a compulsion to touch his chin to his shoulder (five times on each side or else something terrible would happen), she called him on it. The boy denied cheating—he wasn’t cheating, of course—but he was too ashamed to tell her what he was doing. His unexplained denials got him sent to the principal’s office.
An interviewer has to be persistent in his questioning. It can take a while to persuade a child to talk about his problems, even when he’s obviously in pain. Here’s how a conversation might go.
“Everyone has silly habits. Do you have any silly habits?”
“What do you mean?”
“Well, some people feel as if they have to check themselves. Sometimes they have to check themselves more than once even though they know they’ve got it right.”
“You mean like when I have to check my homework to make sure I didn’t make any mistakes?”
“Well, that’s a good habit. What about the times when you check and you don’t need to, like when you leave your room and you go back to check that the light is off.”
“My mother always tells me to make sure the light is turned off.”
“Yes, that’s good. But what about when you check to make sure the light’s off even though you already know it’s off?”
Very young children present a special challenge during these interviews. A three-year-old who makes his parents tie and untie his shoelaces five times on each foot every morning, until they feel equally tight, is unlikely to be able to explain why he needs it. He doesn’t know either why the closet door has to be closed a certain way. A four-year-old child whose compulsion was turning in a circle, always four times in one direction and four times the opposite way, couldn’t come close to formulating an explanation. When I asked him what would happen if he stopped, the best he could come up with was: “If I don’t go in a circle, I feel like crying.”
Children often appreciate and benefit from an explanation of their disorder. I find it useful to talk to a child about habits, discussing various bad habits that people might have. I go on to say that once you start a bad habit, it’s very difficult to break it, and it will probably get worse and worse. I talk about OCD as a disease, like chicken pox, only this time it’s caused by a problem in the brain. I may tell a child that his brain is just forgetting to give him the right messages—for example, that he has already checked to see if the door is locked and that he has washed his hands enough. He is not crazy, and his symptoms are not a reflection of the child any more than the blemishes associated with chicken pox define him. Thus demystified, the symptoms a child has been experiencing can be dealt with with considerably less anxiety.
In the end, when a child is finally persuaded to tell the truth about what he’s been thinking and doing, he’s nearly always incredibly relieved to be rid of his secret. Once the floodgates are opened, most kids can’t stop talking about their problems. After all, they’ve probably never said some of these things out loud before. That little boy whose mother told him to make sure the light was off finally blurted out the truth in a great rush—“Every day I have to touch the light switch a hundred times!”—and then burst into tears. Nearly every child I talk to about OCD ends up crying with relief at some point during the interview.
OCD is a disorder in which symptoms can wax and wane, so it’s important to get information about a child’s behavior from several different sources. We look to parents to provide information about the child’s early development and to describe his current behavior. Perhaps Mom and Dad have noticed that it’s taking longer than usual for the kid to get out in the morning, for instance, or that a child is asking more than the average number of anxious questions: “Did you lock the doors?” “Do you really love me?” Mothers and fathers often interpret this kind of behavior in a child as garden-variety insecurity. Only when they realize that their kid is taking two hours to get ready for school in the morning do they acknowledge that something might be amiss.
Over the course of a day, children may be able to control their obsessions and compulsions for a time. Teachers are often not aware of OCD symptoms because many kids keep their strange behavior under wraps during school; fear of ridicule by your peers is very strong. A teacher may notice oddities—a kid who repeats himself all the time or uses the bathroom more than usual or pays an excessive amount of attention to the arrangement of the items on and in his desk—but in general the school is not a particularly good source for information regarding OCD.
Before a final diagnosis of OCD is made, other disorders with similar symptoms must be ruled out. For instance, children with separation anxiety disorder (see Chapter 9) may appear to have OCD. One example was a schoolboy who would get down on his knees in the classroom several times every day and rock back and forth. At first he was thought to have OCD, but he eventually explained that he was just praying that his parents were all right.<
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Schizophrenia (see Chapter 16), which is very rare in children, may include symptoms similar to those of OCD. Kids with schizophrenia usually look withdrawn. They’re living in an internal world, unlike children with OCD, who are very much with us. A child with OCD recognizes that his fear of germs is illogical, but the child with schizophrenia believes that those germs are a real threat to him or others. OCD may also look like Tourette syndrome (TS; see Chapter 13), an illness in which children have a variety of motor and vocal tics. Unlike the actions associated with OCD, Tourette’s tics are involuntary. OCD often occurs with TS; that is, a child may have both brain disorders at once.
Patients with OCD who are obsessed with fears of contamination may refuse to eat and begin to lose weight, behavior that must be distinguished from that associated with anorexia nervosa. (Some 20 to 40 percent of all adolescents with eating disorders will also have OCD.) A 13-year-old boy named Brian was brought to our emergency room because he was dehydrated. According to his parents, he had basically stopped eating. Anorexia was the first diagnosis that came to mind, naturally, but after taking a history the doctor learned the real story about Brian’s food avoidance. It all started when he refused to eat Reese’s Pieces candies (prominently featured in the movie E. T., Brian’s favorite). Brian was preoccupied with the idea that if he ate Reese’s Pieces, something terrible would happen to him. The fear of Reese’s Pieces led to a fear of peanut butter and then, gradually, to a fear of just about all food. The diagnosis became clear: OCD.
THE BRAIN CHEMISTRY
Animal studies have indicated a neurological basis for many OCD symptoms. These ideas were reinforced by an association between certain neurological illnesses and OCD. For example, there are numerous case reports of people who developed OCD after recovering from encephalitis, an inflammation of the brain caused by a virus or bacteria. We also know that patients who have Sydenham’s chorea tend to have a higher than usual incidence of OCD. (Sydenham’s chorea is a disease of the basal ganglia. Basal ganglia contain a lot of serotonin.) Neuroimaging devices, such as CAT and PET scans, reveal specific differences in the brains of patients with OCD and those without the disorder. All of the differences are in the basal ganglia and the frontal lobes. Neurosurgery treatment in which the basal ganglia are disconnected from the frontal lobes has been successful in severely ill patients with OCD who did not respond to other treatment. Put together, this evidence strongly suggests that OCD is caused by a deficiency of serotonin in the brain. That theory is strengthened even further when we see that medicine that increases serotonin is extremely effective in treating OCD.
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