DIAGNOSTIC INFORMATION FOR TEACHERS, PARENTS  AND SCHOOL PSYCHOLOGISTS ABOUT OCD IN SCHOOL CHILDREN

 (Please note: This paper was written 17 years ago, before recognition of Asperger's Disorder came to the forefront.  Therefore, many of these traits/behaviors will be very common in Asperger's children as well as OCD children.)

OCD (Obsessive Compulsive Disorder) affects at least 2-3% of American school-children, but is one of the most difficult of all conditions to evaluate and accurately diagnose in the school setting.  This brief paper is designed to be a guide to improved diagnostic efforts and referral for effective treatment.

It is important to emphasize at the outset that OCD, like Tourette's Syndrome and ADHD (Attention Deficit Hyperactivity Disorder), is no longer considered to be a "psychological" condition.  It is Neurobiological, often genetic, and often linked with Tourette's Syndrome and ADHD.  To be specific, we now know children and adults with OCD have significant neurohormonal overactivity in a part of the brain called the Orbital-Frontal Area (the segment just above the eyes), and impaired neurohormonal activity in another section of the brain known as the right Caudal area.  In a few cases, there is evidence this condition may be generated by autoimmune antibody assault on the Cuadate Nucleus after an infection with Beta-hemolytic Streptococcus ("Strep" infection).  In mostcases cause remains obscure.

Nationwide data suggests fewer than 5% of schoolchildren are ever accurately diagnosed with this condition, which is tragic since obsessions and compulsions TORTURE the child over time, and without treatment may lead to lifelong impairment with devastating consequences, even in our best and brightest (e.g., Howard Hughes).  This condition can destroy academic and vocational careers.

OBSESSIONS are unwanted, intrusive thoughts which constantly enter and re-enter one's mind despite efforts to block them out.  They may be ideas, images, or impulses - or all three combined - and they generate tremendous anxiety.

COMPULSIONS are behaviors employed, over and over, to try to get rid of the obsessive thoughts by some ritual-like repetitive behavior, carried in many cases to considerable extremes.

FIXATIONS are even more prominent in children with Aperger's Disorder.  These children tend to get angry when they cannot focus on specific areas of intense interest.  Children who have OCD get anxious when they cannot use a compulsive behavior to address the fixation/obsession.

Until mid-adolescence, boys are far more often affected by OCD than are girls; in some studies boys were 5:1 more likely to have OCD, a ratio closely comparable to ADHD-Hyperactive/Impulsive Type and Tourette's Syndrome.  Further, it appears OCD clusters especially among fairly bright children with a lower incidence of Learning Disabilities than found in Tourette's/ADHD children.

Children with OCD very commonly have intense but very secret preoccupations about and/or superstitions over certain numbers, and may be constantly mentally counting and checking numbers.  Some children who have seemingly unexplainable emotional reactions to joining certain games and activities may in fact be reacting to their anxiety over being on a "team" of seven; in their mind anything and any activity not associated with even numbers is intolerable!  For similar reasons some OCD children cannot tolerate games like "Four Square," and will never play hopscotch since that would involve stepping on a forbidden number, or they might mess up and touch one of the lines ("breaking their mother's back").  By age seven or so OCD children are usually well aware their fears, superstitions and odd ideas are unusual, thus only a teacher or school nurse or psychologist who is very astute will be able to get them to admit why they can't play some games of this kind.

Many children with OCD handle transitions poorly because they are not "finished."  To them being "finished" means something very different than to anyone else.  The task may be an English assignment reading a page or two of a story, but their idea of finishing is when they have counted all the A's and found a way to make them divisible by four, or "framed " the story into several constituent quadrants, or checked if all the "i" and "t" letters are exactly on line and dotted and crossed precisely, etc.

The question arises: how to probe into 'why?'  The answers are:  ask questions which gently tap into problems such as getting ready for school.  "Are you having a lot of trouble getting ready in the morning?  Do you  find yourself having to do some things over and over before you get them right?  Do you find yourself checking and re-checking your hair or clothes a lot?  Do you have to check things in your room a lot?  Do you have doubts that everything is right and need to go back and check again, or look at your hair or clothes again, or change clothes several times until everything matches?  Are you kinda over-concerned about certain color matches and worry the color pattern is not right?"

Most kids, when asked these specific questions, will eventually answer honestly.  They would never openly admit to these problems if asked:  " Are you having a problem with lots of bathing and dressing and clothing rituals?"  But they often admit to the specific problems when questions are posed discreetly and in a sympathetic manner, especially if a nurse or principal were to say something like, "Sometimes I am concerned my clothes don't match and I am late because I have to go back and change too often.  Does that ever happen to you?"

WHAT TO WATCH FOR


1.  Fears of contamination by anything "dirty" are common obsessions.  Children who seem overly preoccupied with anything related to dirt, soiling, stains, or being touched by anything that might seem soiled or dirty, may be expressing one of the more important symptoms  Boys who seem reluctant to play active games on the playground, sand or grass fields may be experiencing fears of contamination indirectly.

Multiple trips to the bathroom, of course, should immediately trigger further concern; this is often a tip-off to excessive washing, not a weak bladder!  Of special concern would be children who seem to need to wash or use the bathroom after using mud, clay, chalk, sand, or paints...beyond typical childrens' responses to these 'hands-on' materials.

2.  Aversion to other seemingly typical classroom activities is often seen in OCD children, such as having to be in a circle or a line (because for some OCD children the circle will never be perfect nor the line straight enough!)  For some others there will be resistance about putting papers or drawings up on the wall (the papers are not perfectly even and the drawings are never really straight).  In many cases, written or art work is NEVER "good enough!"

3.  Inability to tolerate certain seating arrangements is common: a child who is obsessed with everything being divisible by two or four will have immense difficulty sitting in the third row!  He/she may feel comfortable only in the second seat of the second row!  Others, preoccupied with 3-6-9 thoughts, may find working at a small table in a group of four intolerable.  Children who seem unduly and consistently disturbed by seating arrangements are always OCD-suspect.

4.  Unexplained incomplete work is common for OCD children.  The teacher is well aware from verbal interactions that the child knows the written assignment well, but the assignment at the end of the period comes back only partially done, often with many, many erasures.  OCD children try hard to concentrate on content, but are often preoccupied with the size or the feel of the pen or pencil, the depth of inscription into the paper, the size of the letters to be exactly half the size of the upper case letters, etc.  OVERLY PRECISELY ORGANIZED WRITTEN WORK is very commonly seen in OCD children.  Parents may also complain they take hours to get homework done.

5.  Tardy again! And again! And after all manner of corrections and warnings tardy yet again!  Yet he/she seems like such a nice kid and there does not really seem to be a deliberate quality to this.  The parent seems cooperative but complains the child can't seem to get ready in the morning on time.  Many children with OCD have to go through a number of 'rituals' in the morning, especially involving toilet, bathing, dressing and other personal hygiene issues, and then double and triple checking to make sure everything is done 'just right,' and they can never be ready for anything on time - ANYTHING!  Recurrent tardiness is a behavior which should always alert school officials to further evaluated for possible OCD.  By 6th or 7th grade, and of course especially in High School, tardiness in the morning is extremely common among children with OCD.

6.  Multiple, repetitive questions are often the signal that a child may have OCD.  For many children with OCD, the content of an answer is inconsequential; their focus is that it "sounds right."  They are fixated on the volume, intonation or pitch of the answer, or perhaps the rhythm in which the words are said.  Unless it is said "just right," then they have an intolerable level of anxiety and need to solicit trying again - yet of course they cannot actually define in operational terms how the answer should sound.  This is extremely common among OCD children both at home and at school.  This is also very common in children who have Asperger's Disorder.

7.  All children may be, of course, interested in certain specific things: animals, whales, computer games, certain action figures, etc.  Children with OCD are often not merely 'interested.'  They are fixated on certain themes, and if anything they are learning does not fit into that theme they cannot even tolerate trying to think about it!  For some children with OCD, if the new concept does not lend itself to a mathematical formula of some sort, then it is terribly anxiety-provoking because they cannot otherwise "solve it."  Children who seem unusually fixated or focus on unusual objects or ideas, and who seem unable to be flexible enough to go on to a new, unrelated activity or learning task are often showing signs and symptoms consistent with OCD and/or Asperger's Disorder.

8.  Many children with OCD simply must tap, touch, count and frame certain kinds of classroom materials.  If it is there they count it!  They may have to tap or touch to make sure it is straight.  They may be anxious if the 'numbers' are in their mind 'wrong' i.e., uneven.  They often - very often - 'touch' to great excess, in very unusual circumstances:  themselves, peers, papers, assignments, books, desks, clocks, etc.  Their touching often has the quality of 'evening up,' which in OCD lingo means there always has to be balance and equality: two touches on the right side must be matched by two touches on the left side.

9.  Children with OCD may seemingly require all manner of repetition of certain words, phrases, and concepts.  They often insist upon this repetition, and seem incredibly anxious if the teacher fails to over and over again return to these issues.  Further, at home, they want the same story at bedtime, the same theme, and then again the same story over and over and the same theme. The parent or teacher may eventually sense they are getting exhausted and the child is demanding far too many similar stories, yet when they try to change the child simply cannot tolerate ANY change: it has to be the same story, intoned at the proper pitch, repeated over and over without any change!

SHORT SUMMARY OF KEY BEHAVIORS OF OCD

*  Also seen in children who have Asperger's Disorder
**  Very common in children who have Asperger's Disorder

1.  Fears of becoming "dirty," "contaminated."
2.  Aversion to touching sticky, slimy, gooey substances.
3.  Aversion to being touched by other students or teacher.
4.  Avoidance of sand or grass on the playground.
5.  Multiple trips to the bathroom.
6.  Bathroom requests after recess or lunch or other breaks.
7.  Solitary play during recess or lunch.*
8.  Difficulty joining/working with groups in classroom.*
9.  Difficulty with displaying written work or art work.
10.  Difficulty using chalkboard.*
11.  Often feeling his/her work "not good enough."
12.  Difficulty with classroom seating arrangements.*
13.  Insistence on same seat, same row, certain places in class.*
14.  Unexplained "emotional outbursts" with no evident provocation.**
15.  Lots of "superstitions."
16.  Avoidance of age-normative playground/class games.**
17.  Unexplained incomplete work.
18.  Overly precise organized work.
19.  Overattention to certain odd details in written work.
20.  Multiple erasures.
21.  Recurrent tardiness.
22.  Child appears to be tired, droopy in class.
23.  Appears to be overly inhibited in socialization.*
24.  Appears to have few or no close friends.**
25.  Clothes, hair exceptionally carefully precise for age.
26.  Multiple, repetitive questions.
27.  Anxiety over performance, need for reassurance.
28.  Appears overly concerned about details, "little" things.*
29.  Apparent "fixation" on certain themes, ideas, objects.**
30.  Copes with transition times very poorly.**
31.  Always seems to mention certain specific numbers.
32.  Appears inflexible, copes poorly with changes.**
33.  Evidently taps, touches and counts in precise rhythms.
34.  Touches of taps unusual objects, at unusual times.
35.  Odd symbols written on papers and drawings.*
36.  Odd, "religious" objection to class activities.
37.  Exceptionally attentive to time.*
38.  Anxious, upset when schedules not followed exactly.*
39.  Rarely appears fully relaxed; rarely normatively playful.*
40.  Often appears solemn, worried, "nervous."
41.  Frequent somatic complaints: stomachache, headache, etc.
42  Often unable to complete work on time.
43.  Appears unusually vigilant, watchful, "on guard."
44.  Rarely appears to "horse around."**
45.  Often seems to misunderstand the point of others' jokes; when telling own jokes the point may be obscure to everyone else.**
46.  May often appear "off in own world."
47.  Peers tease frequently, brunt of jokes, considered "odd," "weird."**
48.  Expressive speech may be convoluted; talks a lot, but takes forever to get too the point.  May seem unable to complete the idea.*
49.  Unusual ritualistic behavior evident in class.*
50.  Behaviors change after inquiry or when being observed.

IN SUMMARY

Since OCD can, and so often does, have such a devastating impact on cognitive, academic and emotional development in children and adolescents, and since the condition is now so readily , safely and effectively treatable, it is advisable to extend our best efforts to evaluate, diagnose and treat children with this disabling condition as early as possible during their school years.

Corydon G. Clark, M.D.