Obsessive Compulsive Disorder in Atypical Child and Adolescent Development

Symptom Picture

Obsessive Compulsive Disorder can be determined by continuing extreme obsessions and compulsions that produce severe distress and hinder functioning on a daily basis. Usually, it initiates in adolescence or even in young adulthood and is seen in 1 in 200 children and adolescents (American Academy of Child & Adolescent Psychiatry 2018). According to the World Health Organization, one of the top 20 causes of illness-related disability is OCD worldwide, particularly for individuals between 15 and 44 years of age (BeyondOCD.org, 2018). Some of the obsessions experienced by adolescents are repeated and insistent thoughts, impulses, and even images that are unwelcomed and produce noticeable anxiety and distress. Commonly, they are impractical and illogical. They are not simple and can be complex for even the adolescent to understand but still feel the need to act upon. These are not just exaggerated worries about life problems and concerns. “The most common obsession children and adolescents experience are contamination” (Childmind.org, 2019). Kids can worry about being sneezed or coughed on, touching things that are dirty or getting sick from sitting next to someone in class or on the bus. Another common obsession for children is magical thinking. This is when kids believe in superstitions on the utmost level. They take superstitions that are normally used for fun and as a cultural connection as real-life danger. An example of this are “step on a crack, break your mothers back,” a child may worry their thoughts can literally change reality and, in this case, actually cause their mother’s back to break if they stepped on a crack. Catastrophizing is another common obsession with younger children that quickly jump to the conclusion that something devastating happened. For an example, if the child’s parents are late picking them up the child immediately would have thoughts that are not practical, like the parents are trying to abandon him or her. “Scrupulosity is when kids have obsessive worries about offending God, or that they are committing sins daily, and God will be upset with them” (Childmind.org, 2019). Many children are distressed by “what if” thoughts which distress them further causing anxiety. Obsessions interact with compulsions and actually help comfort the anxiety or stress that they experience.

Compulsions are recurring behaviors or rituals. Examples are like keeping things in order, hand washing, ensuring something repeatedly. They can be also be mental acts, such as repeating words silently and counting. (American Academy of Child & Adolescent Psychiatry 2018). Compulsions are also more easily seen then obsessions, but some can be mental like ones described above including praying and counting.

OCD causes significant anxiety and distress, and halts the child’s daily functioning, academic performance, and relationships with peers, friends and family. Prevalence: The worldwide prevalence of obsessive-compulsive disorder (OCD) is approximately 2% of the general population. (Sasson et al 2019). 1 in 200 children and adolescents (American Academy of Child & Adolescent Psychiatry 2018). About 30% of OCD sufferers primarily experience symptoms of the disorder during childhood. It is estimated that 2.2 million Americans suffer with OCD.

Cultural Variables

OCD is found worldwide, including but not limited to, Canada, Puerto Rico, Germany, Korea, Hong Kong, Taiwan, India, and New Zealand, all having very different cultural backgrounds. The findings are different because of the factors that play a part in their day to day living, such as the person’s surrounding environment, cultural background, and personal deep-rooted issues. Based on the studies by the Betham Science publishers, US, Puerto Rico, and New Zealand stated a larger amount of individuals obsessions only in comparison to Korea where the most of the subjects suffered compulsions only. OCD symptoms in Asian countries are found to be similar to those in Western countries. One study, by the American Journal of Psychiatry 2008, presented that OCD is less based upon culture and closer to a neurobiological phenomenon. Some of the shared symptoms are contamination or repeated washing, symmetry and repeating and ordering, hoarding, and continuous checking (Anderson 2008). Asian Americans also informed higher levels of obsessive beliefs.

In subcultures of the US, African Americans are also seen with elevated obsession with cleanliness and contamination as well as obsessions regarding tremendous worries about animals. However, there are concerns with the low participation rate of African Americans for this specific research, since most of them were not interested in further treatment, consequently it affects their prevalence rate. Approximately, only 20% of the African Americans studied took SSRI medications for treatment (iocdf.org, 2016). For Hispanics, since the 2000s there has been very little research to show correlation to any specific symptoms with OCD and their prevalence, but out of those who have participated in studies 29% had attempted to treat it, while others considered it a normalized part of their daily struggle, and assumed a psychiatrist would not be able to assist (Ruscio, Stein, Chiu, & Kessler, 2010). The only Latino country that seems to be involved in research and promoting treatment for OCD is Brazil. Research has shown that non-US citizen immigrants are less likely to obtain mental health care services. Some Native American communities that are not involved with American culture and lifestyles do not associate with the typical clinical structure for mental health and there are a few number of individuals that have participated in research specifically regarding OCD. Overall, US has produced the most research and is the most open about speaking up about mental health so the data from research discussing dynamics on symptoms and cultural effects are large.

Age of Onset and Gender Features:

The typical age of onset varies as some children are unaware of the reasoning behind their obsessions and compulsions. Most research shows that the age of onset for most adolescents is a range between 9-12. Most adolescents report around age 10, when they become more aware of their abnormal symptoms, and they are around people that do not have any. Many children do not like to confer their fears and specific behaviors caused by OCD, because they are embarrassed of their rituals and worry about being teased by friends and possibly even family. Their anxiety increases because of this and also promotes a thought process allowing them to feel they can lessen their obsession with a certain ritual, and everything will be tolerable. In the DSM-5, it states that “young children may not be able to articulate the aims of these behaviors or mental acts.” The majority of onset of OCD is gradual and acute, but in some rare cases it can be indirect. Pre-pubertal OCD is known as early-onset OCD, and those after puberty are known as late-onset OCD. Most individuals are diagnosed later at 19, typically with an earlier onset for boys than in girls. In early youth boys present more than girls. In later adolescence it is equal in both boys and girls. (National Institute of Mental Health 2018).

Etiology

Using neuroimaging technologies, where pictures of the brain and its functioning are taken, researchers determined that specific parts of the brain function differently in people diagnosed with OCD compared to normal people. Symptoms experienced may be caused by communication issues between different parts of the brain. This includes the “orbitofrontal cortex, the anterior cingulate cortex, the striatum, and the thalamus” (BeyondOCD.org 2018). There can also be irregularities in neurotransmitter systems, chemicals like serotonin, dopamine, glutamate responsible for sending messages within brain cells are impactful factors in this disorder. Research evidently shows that OCD has a neurobiological basis, but it has been incapable to identify definitive causes of OCD. Overall, it has been proven that OCD is an outcome of the combination of neurobiological, genetic, behavioral, cognitive, and environmental factors, activating the disorder. Based on a study funded by the National Institutes of Health, that studied DNA, results proposed that OCD is perhaps linked with an unusual mutation of the human serotonin transporter gene (hSERT). (BeyondOCD.org, 2018). Approximately 25% of OCD diagnosed people have someone in their immediate family also suffering the disorder. Additionally, research with twin studies reported when the twins are identical and one is diagnosed with OCD, it is presumed the other is more likely to have OCD, in comparison to fraternal twins, where it is more uncommon. (BeyondOCD.org, 2018). Some more psychological research administered by learning theorists, indicate that behavioral conditioning is correlated with the progress and continuation of obsessions and compulsions. They suggest compulsions are learned responses that aid individuals in lessening or avoiding anxiety, stress and discomfort accompanied with obsessions or urges.

Course

OCD mostly will be a lifelong chronic course. There are changes that occur in the presentation of this disorder, especially when young adolescents realize that their behavior is abnormal. This may cause them to worsen, becoming more anxious or they can improve by getting the help they need to stop their obsessions and compulsions. If untreated, OCD is usually chronic and will be fluctuating, worse on some days and better on others, all depending on the mood and overall strength of anxiety. Sometimes symptoms can improve for months or even years unfortunately only to return much worse and unhealthier than before. The course is fluctuating and heavily dependent on the mental state and environmental surroundings of the individual. “Only 5% to 10% of adolescents with OCD experience a spontaneous remission” (Goodman MD 2018). Dr. Goodman, a psychiatrist, states that “it is better for most people with OCD to keep busy.” (Goodman MD 2018). Being isolated is harmful and allows the individual to have an increased growth of obsessional thinking. Deviations of the level of relentlessness of OCD may be interrelated to variations in the internal chemical environment of the body and brain. Depending on a person’s positive mental state and supportive environment, the course of OCD can transform and be much easier to combat, but there is no guarantee symptoms of obsessions and compulsions will not come forth or be worse than before, which has been seen in various cases.

Prognosis

Since OCD is a chronic disorder with a wide range of potential symptoms it is difficult to say what the person will be like in old age. Without any form of treatment, a person can possibly experience a lifetime of compulsions and obsessions that wax and wane without any notice. The disorder may cause or lead to other comorbid disorders like “anxiety disorder, feeding disorders, depression, tic disorders, body dysmorphic disorders etc..” (BeyondOCD.org). These comorbid disorders mostly occur when the person has not had any help or treatment and have dealt with OCD without any support (BeyondOCD.org). Most cases of OCD can actually improve greatly after only a year of diagnosis. The person’s willpower and want for change in their lifestyle is a significant factor in their prognosis. Even though OCD is chronic and will usually remain with the person in some form, there is a possibility of remission or at least improvement for their day to day living.

Treatment

The treatment of OCD requires both psychotherapy and medications. The most effective evidence-based treatment for OCD is Cognitive Behavior Therapy. (KidsHealth.org 2018). Usually, people also see a therapist to discuss their day to day struggles, which helps them reduce overall stress and anxiety, and learn tips to prevent or diminish their continuous struggles with compulsions. Receiving treatment can benefit most people with OCD and achieve substantial relief from their symptoms permitting them to regain significant control over their daily lives. Children acquire through CBT tactic on how to face their fears and learn to cope with them. A behavioral therapist can create a treatment plan that is specific to the individual trying to gradually reduce the amount of time they have urges to complete rituals and compulsions. This will be advantageous to the prognosis of their OCD and aid them in generating their own coping mechanisms that do not involve abnormal forms of treating their worries and anxiety, like the repetitive practices such as counting, praying, and checking that they are used to doing. (KidsHealth.org 2018). Commonly, a conjunction of medicine and therapy is the most efficient from of treatment. Medicine is typically used to help with the anxiety factor. Adolescents are given SSRI’s, or selective serotonin reuptake inhibitors, like Zoloft, Prozac, and Luvox. Conjoined with those type of medications, antidepressants are utilized to reduce obsessive thoughts and compulsive behaviors by increasing the level of serotonin in their brain. Some severe cases of OCD are even treated with antipsychotic medications. Relaxation techniques like yoga, breathing exercises, physical exercise, and meditation are also helpful for adolescents and children that deal with stress from their symptoms. “Exposure-based therapy can be very helpful as it gradually exposes the patient to their feared scenarios, but it is done with the help of a supportive counselor in a calm environment where the patient is able to assert his or her needs during the process”( American Academy of Child and Adolescent Psychiatry 2018). Family members of diagnosed OCD adolescents are recommended to be aware of the chronic nature of OCD and the prominence of skills in self-management. There are numerous treatment options that help the overall course of OCD and are essential to actually making an improvement on the child’s life and mental state. Without treatment, the child will suffer through more anxiety, depression, worsening of their symptoms, and an increase of obsessions and compulsions.

Differential Diagnosis

Tourette’s syndrome is similar to OCD and sometimes can be misdiagnosed for OCD. Specifically in this syndrome, adolescents can have motor or vocal tics that are normally involuntary, this is paralleled with the repetitive behaviors of OCD that is the outcome of cognitive issues and the necessity of performing an action repetitively or until it is completed “just right.” (Fenske Peterson 2018). Tourette’s can also be identified as different from OCD if the symptoms are not attributed to compulsions and obsessions. Since the symptoms are involuntary, they differ from the deliberate symptoms of OCD. (HealthyChildren.org 2018). OCD obstructs the daily mental functioning of the child abundantly more than the symptoms of Tourette’s syndrome, and the onset, on average 7 years old, and course entirely differs from OCD.