It's Nobody's Fault

by Harold Koplewicz

  The brain disorder that causes OCD runs in families; recent studies show that 20 percent of all youngsters with OCD have a family member with the disorder. Sometimes it takes a little digging to discover who the “donor” in the family is. I’ve talked to parents who at first claim that there’s no family history of OCD, but nine times out often they change their minds. “Wait a minute,” someone will eventually say. “What about your brother? Didn’t he used to shrug his shoulders all the time?” or “Don’t you remember? Cousin Betty used to go up to the attic 20 times a day to see if the fan was on.”

  More often the family connection is more obvious and immediate. One mother whose little girl I diagnosed with OCD wakes up at five o’clock every morning and cleans the entire house, scrubbing the bathrooms at least twice. Her husband says that the family spends more money on cleaning products than on groceries.

  THE TREATMENT

  The recommended treatment for OCD is a combination of behavioral therapy—most notably exposure and response prevention—and medication. If children are not in great distress, a doctor may find it worthwhile to try behavioral therapy first without the medicine, but most kids who end up in a doctor’s office because of OCD symptoms need the relief that medicine affords.

  One child with OCD I treated, an 11-year-old boy named Daniel, used to spend hours getting ready for school in the morning. He said he “got stuck” in the shower; he’d start washing and almost couldn’t stop. Despite his symptoms Daniel wanted to go to sleepaway camp for a couple of weeks, and his parents decided to let him give it a try. It’s not difficult to imagine what his fellow campers and his counselors thought the first time they saw Daniel “stuck” in the shower. After about ten minutes under the spray Daniel was dragged bodily out of the shower and berated. “You’re nuts!” the campers shouted. “Get dressed right now!” said the counselors. “If you don’t dress yourself, we’re gonna dress you.

  Those young campers had no way of knowing that they had invented their own variation of one of the most effective forms of behavioral therapy for OCD: response prevention. In response prevention the patient is forced to confront his worst fears and, ideally, work his way through the anxiety created by a given situation. Some experts call it “letting the anxiety burn itself out.” Response prevention is based on the fact that the body can’t maintain a state of anxiety for more than 90 minutes; most people can manage only about 45 minutes.

  In treating a child with OCD a therapist will conduct an extended session in which a child has to live through the anxiety. For example, a little girl who can’t bear to have dirty hands is forced to make mud pies and then sit quietly for an hour without washing. Another child terrified of germs is led to a chair and then told that someone very sick has just been sitting there. The goal: to teach a child to break the connection between anxiety and that condition. Obviously it’s necessary to involve the parents in a child’s treatment for OCD—as always, mothers and fathers are indispensable co-therapists—but a qualified behavioral therapist is necessary to guide and monitor this sensitive process. A manual and a 16-week behavioral treatment program—both called “How I Ran OCD Off My Land”—have been developed for the treatment of children and adolescents with OCD.

  Most experts agree that behavioral therapy is especially effective in combination with medicine. The drugs prescribed for OCD most often are the SSRIs (selective serotonin reuptake inhibitors): Luvox, Paxil, Prozac, and Zoloft. Currently, Luvox is the only SSRI with FDA approval for use in children with OCD. Anafranil, a tricyclic antidepressant (TCA) that inhibits serotonin, is also effective in treating OCD. Normally we see the results of medication within two to six weeks. The most common side effects of the SSRIs are nausea, diarrhea, insomnia, and sleepiness. Anafranil’s side effects include sleepiness, dry mouth, constipation, and the more serious cardiac effects of all TCAs. To be on the safe side, we always measure a child’s heart rate and blood pressure and do an electrocardiogram before starting a child on Anafranil and before increasing the dosage.

  Just about all children will need to stay on the medication for six to nine months, during which time they should undergo behavioral therapy as well. After they’re taken off the medicine, children should get follow-up evaluations on a regular basis, and they will also benefit from “booster shots” of behavioral therapy.

  Some children being treated for OCD with medication will demonstrate only a partial response or will respond fully but then “break through” the medication with a recurrence of symptoms. When either of those things happens, we first try to improve the response by increasing the dose of the original medicine. If that fails to achieve the result we’re looking for, we’ll try augmentation: that is, we’ll prescribe an additional medicine that will makes the original drug more effective. (Some people think of it as a “chaser.”) The second medicine we prescribe will also take aim at any secondary symptoms that are associated with a child’s OCD. If he’s moody, we’ll add lithium; if he also has ADHD symptoms, we’ll try Dexedrine; Haldol will be added if the child has tics; and we prescribe BuSpar or Klonipin if the child’s secondary symptom is anxiety. It may take a few tries to find the right combination, but some combination nearly always works.

  As I’ve said earlier, parents who are reluctant to give medicine to their children, especially very young children, should be mindful that while there may be negative side effects of the medicine, there are also negative effects connected to not taking the medication. The youngest child I’ve ever treated with this disease was four years old, and I prescribed Prozac for him. What are the long-term effects of giving a kid Prozac (and thus changing his serotonin metabolism) at the age of four? No one knows for sure. What we do know is that a child in pain has to have some relief. That four-year-old I treated was completely unable to function; his many habits—turning in circles, shrugging, hopping, and scratching—had completely taken over. After four weeks on low doses of Prozac he was behaving like a normal, happy four-year-old.

  Recent studies show that cognitive behavioral therapy is not particularly useful in the treatment of young children with OCD, age five and under. Cognitive therapy requires the active participation of the patient, and small children simply aren’t up to the task. For the little ones—as young as three—we recommend medication alone.

  The prognosis for OCD is quite good; the overwhelming majority of kids receiving medicine get better. However, their relapse rate is high. A combination of medication and cognitive behavioral therapy makes a relapse less likely once the medicine is stopped. For obvious reasons, the more promptly the disorder is treated, the better the results are likely to be. The longer a child holds onto a symptom, the more the undesirable behavior will be reinforced. A habit can quickly grow into a way of life.

  Left untreated, OCD can be virtually crippling to a child. Symptoms will probably increase and grow, until he can’t function properly at school or enjoy time with friends. Scholastically and socially OCD takes its toll on a child, seriously limiting his ability to develop and thrive. Also, not surprisingly, OCD creates serious problems with self-esteem. After all, it’s hard for a kid to feel really good about himself if he thinks he’s going crazy.

  PARENTING AND OCD

  I walked out into the waiting room of my office one day and saw a teenage girl with her mother. The girl was sitting in a chair with her mouth wide open, and her mother was standing over her, peering into her open mouth. “No, your tooth is smooth,” I could hear the mother saying. “Your tooth is smooth,” she repeated. Then the mother said it a third time. As I learned moments later, the daughter was obsessed with the notion that her teeth were jagged, and she needed to check them often. When the girl was by herself, she used a mirror that she carried with her all the time. When her mother was around, the mother conducted regular checkups.

  A 10-year-old boy with a cleanliness obsession takes several showers a day. His mother stands outside the door and hands in fresh towels to the boy, sometimes as many as half a
dozen per shower.

  Whenever she walks outside, a six-year-old girl has to keep checking the bottom of her shoes to see if she has stepped in something. Several times a block she stops dead in her tracks to take a look. Her increasingly impatient parents have taken to carrying her to and from the school bus and the car.

  Many children with OCD involve their parents in their rituals, and parents, eager to keep the peace, may become unwitting accomplices, important players in a child’s disorder. (Alcoholics Anonymous calls such people “enablers”—people who make it possible and even easy for an alcoholic to live with his disease.) Parents should resist the temptation to make it easier for a child to indulge in rituals. If the treatment of OCD is going to be effective, parents have to help their children give up the symptoms. Doling out clean towels to a germ-obsessed kid or carrying a child down the street so that her shoes don’t touch the sidewalk isn’t a solution; chances are it contributes to the problem.

  Of course, it’s not always easy for parents—or anyone else, for that matter—to take a hard line with a child obviously in distress, but most families have their limits. Nathan, nine years old, was obsessed with the idea that his family was using too much water and electricity. “That’s too expensive. Turn that off,” he would say to his father, who was using an electric razor to shave, or to his mother, trying to toast frozen waffles for the family’s breakfast. “Don’t take a bath. It wastes water,” he screamed to his older sister. Just before they came in to see me, Nathan had begun walking around the house in the evening and turning off all the lights. When anyone complained, he would usually have a tantrum. His parents knew that Nathan’s behavior was unacceptable, and we worked together to come up with a plan to deal with Nathan’s demands as well as a trial of medication to alleviate his symptoms.

  Kids with OCD can be remarkably dislikable, even to their loving parents. “I know this is going to sound cold and awful, but it’s gotten so I really don’t like my son,” a sorrowful mom said to me not long ago. The boy she came to see me about, Lonnie, age ten, was indeed not likely to win any popularity contests. Exceptionally good-looking, with olive skin, green eyes, and dark curly hair, Lonnie was also exceptionally obnoxious. He had a persistent shoulder shrug, but when I asked him about it, he denied it, quite rudely. Throughout our conversation he was fidgety and provocative. When I asked him what he enjoys, he said, “I love sharks. I love violent movies. I love seeing heads being ripped off.” Then he started imitating the voice of Chuckie, the evil doll from the movie Child’s Play. His parents told me he fights with them and his siblings all the time, and he’s recently been having trouble at school with both his classmates and his teachers.

  To all outward appearances Lonnie was a difficult, oppositional, spoiled brat. It was only when he made some very unusual demands on me—the strangest was asking me to curse at him loudly from across the room—and explained that he wanted me to do it to keep something bad from happening that I looked past the bad behavior and detected the symptoms of OCD.

  Once in a while a parent faced with a child’s OCD just snaps. One distraught father, his eyes filled with tears, told me about the night he lost his temper with his 11-year-old daughter, Renée. Night after night Renée would bang on her parents’ bedroom door, screaming, “Do you love me? Am I attractive?” “Yes, you’re very attractive. Go back to bed,” Mom and Dad would tell her. “Do you mean attractive or do you mean pretty?” she’d ask. “Do you mean pretty or do you mean beautiful?” was next. They kept responding and kept telling her to go to sleep, but it was never enough. The banging and crying went on for hours. Completely frustrated, the father finally dragged Renée back to her room and locked her in. When he described wedging a chair against his daughter’s door, he broke down.

  As amazing as it may seem, some parents are unaware of OCD in their children. Even parents who realize that their kids have some pretty strange habits are very often stunned to find out just how bad the situation is. A 16-year-old girl with crippling fears about germs and dirt came to see me. She washes her hands dozens of times a day. She’s disgusted by and scared of bodily functions; she’s never had sexual intercourse but is terrified of getting pregnant. Her mother does the laundry for the family, but the girl says her clothes are never clean enough to suit her. For a year now, without her mother’s knowledge, she has been washing her own clothes, sometimes as often as five times a day. The week before she came to see me she finally let down her guard and told her parents.

  According to the mother of 12-year-old Howard, he’s always been “fussy about his clothes.” His undershirts have to be skintight, and he’ll wear only one brand and color of pants. He has five pairs of identical pants and wears a pair every day to school. No one in the family thought too much about Howard’s strange notions about wardrobe. After all, everything else about him was normal, or so his family assumed. One day Howard was typing out a report for school. Somewhere in the middle of the paper he realized that every time he typed the letter s, he felt compelled to hit the space bar. Soon he couldn’t stop doing it, and he got scared. Fortunately he confided his fears to his mother and father, and soon thereafter he was in my office. It turns out that Howard had a host of other painful habits that he had never told anybody about.

  There is some debate among professionals about whether or not to involve teachers and other school officials in the treatment of OCD. As a general rule I’m in favor of full disclosure, of letting the school know about a diagnosis of OCD and working out a strategy for managing the problem, but only if the symptoms are affecting a child’s performance or behavior while he’s in school. There’s no question that OCD can manifest itself in behavioral problems—for instance, a child who keeps jumping up out of his seat and running to the bathroom to wash his hands is more than a little disruptive to the rest of the class—and a teacher is entitled to know why the kid is doing it. Once the lines of communication with the school are open, decisions can be made about how a teacher will respond. On the one hand, a child should not be punished for behavior over which he has no control. On the other hand, teachers must maintain order in the classroom, and there’s no way they can do that without holding children responsible for their actions. OCD or no OCD, actions must have consequences. With the help of a professional, parent and teacher should be able to work out some realistic guidelines.

  I always suggest that teachers choose their battles carefully when confronted with a child who has OCD. Some children will write only with a pen, drink from only one special water fountain, or use only one bathroom. Those behaviors, while certainly not ideal, do not significantly disrupt the classroom, nor do they interfere with the child’s learning, and I recommend that a teacher ignore them if possible. However, the more disruptive behaviors—talking out of turn, making broad gestures, and especially leaving the classroom—must be dealt with more directly.

  CHAPTER 9

  Separation Anxiety Disorder

  The first time I saw Jenny, age seven, it was a late Thursday afternoon at her school in a suburb of Boston. She was sitting on her teacher’s lap, crying. When I asked her what was wrong, Jenny said she had a stomachache. I volunteered to help her, but she told me not to bother. “This is my Monday through Friday stomachache,” she told me. “Today is Thursday, so I just have one more day to feel bad.” I asked if there was anything that would make the pain go away, and she answered immediately: “Bring my mother here.” A few weeks later Jenny’s parents told me more about their daughter—how she’d sneak into their room at night and sleep on the floor, how she had to be forced onto the school bus every morning, how she would often ask them when they’re going to die. When Jenny’s goldfish died, she mourned for weeks.

  Nine-year-old Ernie came to see me after he’d missed four months of school. He had had trouble with school ever since kindergarten, but by the fourth grade he was in terrible distress. When his parents tried to get Ernie to go to school, he complained of headaches, stomachaches, and fatigue. In the p
revious four months he had been in and out of the hospital with various infections. Ernie was inordinately anxious, especially about leaving his parents. He had trouble sleeping in his own bed and crept into his parents’ room nearly every night. He didn’t want to be with his friends after school because he worried about what would happen to Mom and Dad; even when he was away from home for a short time, he’d become homesick. Recently he wasn’t sleeping even on weekends, and his appetite had decreased dramatically.

  THE SUNDAY NIGHT BLUES

  Nearly everyone knows what separation anxiety feels like. Changing jobs, taking a vacation, even spending the night away from home can cause discomfort. When I was a kid, I used to get a lump in my throat every time I heard the theme song from Bonanza, not because I was moved by the adventures of the Cartwrights but because that music, coming as it did on Sunday night, meant that it was almost Monday morning. My weekend was nearly over, and I wasn’t prepared for school. I didn’t know then that I was suffering from the “Sunday Night Blues,” a common response.