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 repet.i.tive 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 h.o.a.rding.

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 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 rea.s.sured. 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 rea.s.sured.

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 really the right weight? Is it exactly the right weight?" he asked. I could sense his anxiety. It all but overwhelmed him. "This is the right weight? Is it exactly the right weight?" he asked. I could sense his anxiety. It all but overwhelmed him. "This is exactly exactly the right weight for you," I told him. He calmed down almost immediately. 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 safest plane?" plane?"

"All of our planes are safe."

"But is this the safest safest plane?" plane?"

When the stewardess didn't answer Stuart's question for the third time, he became extremely agitated. "Is this the safest safest plane?" he repeated. "If you don't answer me, I'm going to kill you." 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 rea.s.sure 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 The Boy Who Couldn't Stop Washing, knows that one of the most common symptoms a.s.sociated 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 OCD and IQ. Jake was an extremely bright kid with a high IQ, who eventually became cla.s.s 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 ch.o.r.es 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 rea.s.surance 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 embarra.s.sed 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 a.s.sociated with OCD. One boy I treated was caught "cheating" in cla.s.s. 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 was doing. His unexplained denials got him sent to the princ.i.p.al's office. doing. His unexplained denials got him sent to the princ.i.p.al'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 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 a.s.sociated 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 Chapter 9) may appear to have OCD. One example was a schoolboy who would get down on his knees in the cla.s.sroom 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.

Schizophrenia (see Chapter 16 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 Chapter 13), an illness in which children have a variety of motor and vocal tics. Unlike the actions a.s.sociated 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 a.s.sociated 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. 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 b.u.t.ter 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 a.s.sociation 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 ch.o.r.ea tend to have a higher than usual incidence of OCD. (Sydenham's ch.o.r.ea 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.

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 exposure and and response prevention 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: 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 a.s.sociated 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. 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 a.s.sociated 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 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. 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 partic.i.p.ation 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. 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. 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. 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 cla.s.smates and his teachers. 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 cla.s.smates 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, Renee. Night after night Renee 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 Renee 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 s.e.xual 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 a.s.sumed. 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 s, he felt compelled to hit the s.p.a.ce 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 cla.s.s-and a teacher is ent.i.tled 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 cla.s.sroom, 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 cla.s.sroom, 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 cla.s.sroom-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 previous 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 appet.i.te 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 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.

The anxiety that Jenny and Ernie feel is, of course, more serious than my Sunday Night Blues. On Sunday nights Jenny is anxious not because she hasn't done her homework for the next day but because she knows she is about to lose access to her mother. Ernie is not fretting over a forthcoming spelling test. He's worried that something terrible is going to happen to his parents. My diagnosis was the same for both kids: separation anxiety disorder, or SAD.

THE SYMPTOMS.

There is an important difference between separation anxiety and separation anxiety disorder. Children between seven months and 11 months experience stranger anxiety: stranger anxiety: when they see somebody unfamiliar-not Mom, Dad, a relative, or a regular caregiver-they become alarmed. Most children have when they see somebody unfamiliar-not Mom, Dad, a relative, or a regular caregiver-they become alarmed. Most children have separation anxiety separation anxiety between 18 months and three years. For instance, a normal two-year-old whose father goes outside for a few minutes, leaving the child with a family friend, will probably have some separation anxiety. As he leaves, the father might say, "I'll be right back, Sam. I'm going to the car to get something. Talk to Carol." Almost immediately, Sam will start to get anxious, thinking, "Wait. I don't know this person. Where's my father?" That reaction is normal, provided that Carol is able to console or distract Sam so that the anxiety doesn't last more than a few minutes. Another two-year-old playing comfortably outside might well take a break, touch base with Mom, and then resume playing after a few minutes. That's normal too. So is some weepiness in the early days of nursery school. between 18 months and three years. For instance, a normal two-year-old whose father goes outside for a few minutes, leaving the child with a family friend, will probably have some separation anxiety. As he leaves, the father might say, "I'll be right back, Sam. I'm going to the car to get something. Talk to Carol." Almost immediately, Sam will start to get anxious, thinking, "Wait. I don't know this person. Where's my father?" That reaction is normal, provided that Carol is able to console or distract Sam so that the anxiety doesn't last more than a few minutes. Another two-year-old playing comfortably outside might well take a break, touch base with Mom, and then resume playing after a few minutes. That's normal too. So is some weepiness in the early days of nursery school.

However, by the age of four, a child should be able to leave his parents or his home without distress or anxiety, and about 96 percent of all children can do so without a problem. (The fact that many children start nursery school at age four is no accident.) It is estimated that 4 percent of all children have SAD.

Every once in a while SAD makes its first appearance not in the early days of nursery school or in first or second grade but later, during adolescence. The disorder seems almost to "spring up," with no earlier evidence that there was a problem. Often what brings on the symptoms of SAD is a change or a loss. That was the case with two young people I treated for late-onset SAD. Amelia, 15 years old, showed the first signs of SAD when she and her family moved to a new state in the middle of her soph.o.m.ore year of high school. Amelia had always loved school, but she just couldn't adjust to the new setting. Every day there were tearful phone calls home, in which Amelia would beg her mother to come and get her. By the time I met Amelia, she had stopped going to school. In fact, she was refusing to leave her front yard. Her parents were completely baffled by the change in their daughter.

Another "late bloomer" with SAD was 13-year-old Rafael, whose SAD came on after he missed a few weeks of school because of a case of mononucleosis. When he was finally well enough to go back to cla.s.s, Rafael didn't feel comfortable being there any more. He told his parents he was tired and light-headed, and he insisted on staying home, where he would spend the day watching TV and sleeping. When I saw Rafael for the first time, it had been nine weeks since he'd been to school and almost that long since he'd left the house. Before the mono he had seemed perfectly normal, with no symptoms of SAD.

Children suffering from SAD are preoccupied with thoughts that harm is going to come to them or their parents. They feel distress when they have to leave their parents, to go to bed at night or to school in the morning. At school during the day or if they have to go away overnight, they're terribly homesick. Sometimes they experience physical symptoms. Younger children often get stomachaches and diarrhea; older kids may experience dizziness and rapid heartbeat. Their nightmares have a recurring theme: something bad is happening to their family. The house burns down; Mom gets sick and has to go to the hospital; someone evil is chasing the child. Children with SAD don't like to be alone in the house and may shadow their parents, following them from attic to bas.e.m.e.nt. One mother I spoke to said she literally could not go anywhere in the house without having her six-year-old daughter tag along. Children with SAD can have worries that aren't obviously a.s.sociated with the disorder; an eight-year-old boy named Eddie told me he was worried that someone was going to break into his apartment and steal the silver. Why the silver? The family always used the good silver for their special Sunday night suppers.

Kids with SAD can have extremely high IQs. John was one of the smartest children I've ever met. At the age of 10 he had verbal skills way above the norm. He was also one of the best-natured, sweetest kids I have come across. Dressed in his school uniform with his blond Dutch boy haircut, he looked like a youngster right out of a Norman Rockwell ill.u.s.tration. A few minutes into our meeting it became obvious that something wasn't quite right. Increasingly fidgety, John kept looking toward the door, behind which his mother was waiting. Suddenly he ran to the door and opened it to make sure Mom was still there, an act he repeated many times during the visit. I soon learned that John was preoccupied with the thought that his mom and dad were going to die. When he was in school, the idea sometimes upset him so much that he would get down on his knees and pray that nothing bad would happen to his parents.

THE DIAGNOSIS.

The morning nine-year-old Elizabeth stepped into my office, the first thing I noticed were large patches missing from her curly red hair. My first thought was that she was being treated for cancer. I soon learned that her hair loss had nothing to do with chemotherapy. Every night, after she went to bed and was left alone in her room, she would pull out clumps of her own hair. There was nothing compulsive or ritualistic about the hair-pulling; she didn't pull three strands on one side and then three on the other, for instance. She pulled her hair out because she was worried. Elizabeth was convinced that as she slept, someone was going to break into her apartment and do something terrible to her mother and father. Lately her fears had been getting worse, and she'd been refusing to go to school. She was afraid of what would happen if she left her parents at home alone.

SAD can be and often is mistaken for other disorders. SAD is often called school phobia, but that's a misnomer. A child with SAD may not want to go to school, but he isn't afraid of it. Being in school-without Mom and Dad-is what he's afraid of. SAD is sometimes confused with depression. The child may look and act depressed-SAD may result in loss of concentration, sleep and appet.i.te disturbance, and a demoralized state, all symptoms of major depressive disorder (see Chapter 14 Chapter 14)-but, it's crucial to note, those symptoms nearly always disappear when Mom and Dad are around. A child who has no appet.i.te for his lunch at school may eat perfectly well at dinner, when he's at home with his parents. By contrast, the loss of appet.i.te a.s.sociated with clinical depression doesn't come and go. A youngster with SAD may be perceived as defiant, especially when he has to be dragged kicking and screaming onto a school bus. Attention deficit hyperactivity disorder (see Chapter 7 Chapter 7) may also be suspected, since children with SAD are so worried that they often appear inattentive and distracted in school. One mother whose daughter I treated received a succinct but less than helpful diagnosis from her neighbor: "spoiled brat."

Jenny, Ernie, John, and Elizabeth demonstrate a wide variety of anxiety symptoms, but at the core of each is the most important factor in SAD: a threat to the integrity of the family. That's what we look for when we examine a troubled child. And we look for it the old-fashioned way: by taking a detailed developmental history from the parents and interviewing the child. Here's how an interview with a child might go.

DOCTOR: "Everyone worries about something. What do you worry about?"CHILD: "I don't know."DOCTOR: "Some kids worry about tests in school. Do you worry about them?"CHILD: "No."DOCTOR: "Some kids worry about their parents not having enough money. Do you worry about that?"CHILD: "No."DOCTOR: "Some kids worry about their parents' health."CHILD: "Yeah, I kind of worry about that."

The child doesn't always directly acknowledge worrying about his parents. He might talk about kidnappers or burglars or voice concerns about the security of his house. But it doesn't take too long to get to the real fear.

Here's another line of questioning I might try.

DR. K: "When you're at school, tell me what it feels like."CHILD: "I don't know."DR. K: "What does it feel like when you see your mother when you come home from school?"CHILD: "Sometimes I feel like I could cry."DR. K: "You feel sad?"CHILD: "No, I feel happy."DR. K: "Do you ever feel as if there's something pushing on your chest?"CHILD: "Yes, but it goes away after school."

A child need not have all of the symptoms of SAD to qualify for a diagnosis; if a child is suffering, even one or two symptoms are sufficient. As is the case with all brain disorders, SAD is a spectrum disorder, ranging from mild to severe, so along with any diagnosis should come an evaluation of distress distress and and dysfunction. dysfunction. There is a critical difference between a child who is a little uncomfortable sleeping with the lights off and one who is so pained to leave his home and family that he avoids going outside, refuses to accept sleepover dates with friends, or, worst of all, won't go to school. It's not enough for a child to have a rewarding, secure home life. Like a healthy adult, a healthy child should have an active social and "work" life as well. There is a critical difference between a child who is a little uncomfortable sleeping with the lights off and one who is so pained to leave his home and family that he avoids going outside, refuses to accept sleepover dates with friends, or, worst of all, won't go to school. It's not enough for a child to have a rewarding, secure home life. Like a healthy adult, a healthy child should have an active social and "work" life as well.

THE BRAIN CHEMISTRY.

Stephen, 10 years old, had one of the most severe cases of SAD I've seen. I'll never forget the day he first came to my office; rather, I should say they they came to my office. When I opened the door, three generations were sitting in my waiting room, staring up at me: Grandma, Mom, and little Stephen. Stephen was refusing to go to school by himself. He agreed to attend school if his mother would drive him and then sit in the car right outside his cla.s.sroom so that he could see the car through the window. The mother had been doing just that, and the school was remarkably cooperative; the staff agreed to the unusual parking setup and even let Stephen make calls (on the cellular phone he carried) to his mother on the car phone. This strategy had been going on for six months when I met Stephen, but now there was a crisis: Stephen's mother was finding the arrangement more difficult all the time. When she told Stephen that she couldn't take him to school any longer, he threatened to kill himself. When it was time to go to school, he cried hysterically, saying: "I'm going to die. You're going to die." came to my office. When I opened the door, three generations were sitting in my waiting room, staring up at me: Grandma, Mom, and little Stephen. Stephen was refusing to go to school by himself. He agreed to attend school if his mother would drive him and then sit in the car right outside his cla.s.sroom so that he could see the car through the window. The mother had been doing just that, and the school was remarkably cooperative; the staff agreed to the unusual parking setup and even let Stephen make calls (on the cellular phone he carried) to his mother on the car phone. This strategy had been going on for six months when I met Stephen, but now there was a crisis: Stephen's mother was finding the arrangement more difficult all the time. When she told Stephen that she couldn't take him to school any longer, he threatened to kill himself. When it was time to go to school, he cried hysterically, saying: "I'm going to die. You're going to die."

Stephen had SAD, and it doesn't take a world-cla.s.s diagnostician to see where it came from. As I soon discovered, both Grandma and Mom had it as well. They lived a block away from each other and were inseparable. They had never spent a day apart and went everywhere together, including my waiting room. Obviously, the DNA Roulette wheel had spun, and Stephen had an unlucky number. Stephen had inherited his brain chemistry from his mother.

What is it about the chemical composition of that family's brains that results in SAD? What causes SAD? As always, it's difficult to answer precisely, but the most likely answer is an imbalance of serotonin and norepinephrine.

Eve, a 30-year old computer programmer, was waiting for the bus that would take her to work. It was a cool autumn day, but Eve felt hot and clammy. Her heart was racing, and the street seemed to be spinning. She felt dizzy and lightheaded. She was sure she was having a heart attack, so she sat down on the sidewalk. When her fellow commuters asked her what was wrong, she couldn't speak. In fact, she was having trouble breathing. Someone took out a cellular phone and called 911. Moments later Eve was evaluated in the emergency room of a nearby hospital. Her cardiogram was normal, and so, it seemed, was everything else. Eve's symptoms had subsided by then, and more than anything else she was embarra.s.sed. This was the second time that Eve had gone through this, and it looked as if "nothing" was wrong. But the emergency room doctor told her that something was indeed wrong. Eve had had a panic attack. The psychiatrist on call confirmed the diagnosis and took it a step further; she told Eve that she had panic disorder: an adult psychiatric disorder (seen occasionally in adolescents) consisting of panic attacks and worry about future attacks.

SAD seems to be the childhood version of panic disorder. There are all sorts of data to support this theory: landmark studies (conducted by Donald Klein) show that 50 percent of patients with panic disorder had separation anxiety disorder as children; moreover, other studies indicate that the children of adults with panic disorder have separation anxiety disorder more than three times as often as the children of depressed or normal adults; and finally, the same medicines are effective in the treatment of both disorders.

Studying the causes of panic disorder has added immeasurably to our knowledge of what causes SAD. We know that both disorders are caused by a defect in the way the brain recognizes and responds to danger. It all happens in the locus ceruleus locus ceruleus, the part of the brain that alerts the body when there is danger by producing norepinephrine. In people who have panic disorder and, more to the point, children with SAD, the locus ceruleus basically gives the "Danger!" signal when there is no danger, thereby upsetting the balance of norepinephrine and serotonin.