Obsessive-Compulsive Disorder

Edited by Shane R. Jimerson, Ph.D.
Contributed to by the Graduate Students in the Counseling, Clinical, and School Psychology Program at the University of California, Santa Barbara.

Ongoing design and publication of this site is completed by Shane R. Jimerson and Jeff R. Klein. Please forward comments regarding this site to Shane R. Jimerson. This page was last updated 3.9.98. © 1998

Authors- Maria Alvarez & Sandra Macias University of California, Santa Barbara

Symptoms
Epidemiology
Etiology
Assessment
Treatment

Introduction

The functional impairment that has long been associated with Obsessive-Compulsive Disorder (OCD) in adult populations is now being observed in child and adolescent populations as well. In fact, according to the American Board of Psychiatry and Neurology, OCD is considered to be one of the best understood neuropsychiatric disorders within the pediatric population (March & Leonard, 1996). It is estimated that one in 200 young persons meet the criteria for OCD, and that many of these youth experience severe disruption in their academic, social, and vocational functioning (Adams et al., 1994; & Leonard et al., 1993b). Despite the prevalence of OCD and the wealth of knowledge which has recently emerged regarding this disorder, the literature indicates that many adolescents do not receive the proper diagnosis nor the proper treatment when they seek out help (March & Leonard, 1996). Some common causes for underdiagnosis and misdiagnosis of OCD include: the secretiveness and lack of insight that can be part of the disorder; the lack of familiarity on the part of health care providers; and the similarity between symptoms presented with OCD and other mental health disorders.

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DSM-IV (1994) Criteria for Obsessive-Compulsive Disorder

A. Either obsessions or compulsions:

Obsessions as defined by (1), (2), (3), and (4):

        (1)    recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.
        (2)    the thoughts, impulses, or images are not simply excessive worries about real-life problems.
        (3)    the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action.
        (4)    the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion).

Compulsions as defined by (1) and (2):

(1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.

C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.

D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).

E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Specify if:

With Poor Insight: If, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable.

Source: American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.), ( pp. 422-423). Washington, DC: American Psychiatric Association.

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Epidemiological Information

     Although research on childhood OCD has increased dramatically over the past 15 years, Jenike (1989) refers to OCD as a “hidden epidemic”, primarily because the disorder is frequently unrecognized and is therefore underdiagnosed (March & Leonard, 1996). Recent epidemiological studies of child and adolescent OCD suggest the prevalence rate is approximately 1 in 200 with a mean age of onset ranging from 7.5. to 12.8 years (Albano, M., Knox, L., & Barlow, D., 1995; Flament, Rapoport, & Berg, et al., 1988).      Epidemiological studies focusing on adolescent populations have reported a prevalence rate ranging from 2-4%. Retrospective reports of adults with OCD suggest that one third to one half develop OCD during childhood, with one study reporting that 22% had onset prior to age 15 (Rasmussen and Eisen as cited in March & Leonard, 1996; Lo as cited in Albano, Knox, Barlow, 1995). Geller, Biederman, Jones, Park, et al (1998) report that across ten studies of clinical populations, age at assessment was about 2.5 after age at onset. Notably these authors also suggest that a precipitating psychosocial event is associated with onset of OCD in approximately 38% to 54% of children and adolescents.
     Albano, Knox, and Barlow (1995) note that various investigators have found that 50-60% of children diagnosed with OCD experience severely impaired global functioning in personal, social, and academic life. Additionally it should be noted that comorbidity occurs in about 62-74% of children and adolescents with OCD. Comorbid disorders commonly associated with OCD include: anxiety disorders, tics, Tourette’s disorder, learning and mood disorders.
     Recent epidemiological studies have identified a bi-modal incidence pattern, as suggested by one such study’s finding that modal age of was 7, while mean age of onset was 10.2 (March & Leonard, 1995). This suggests that there may be an early onset group and an adolescent-onset group. Among children and adolescent samples boys outnumber girls with OCD by at least 3 to 2. Boys are found to have a greater incidence of prepubertal onset while girls have a greater postpubertal onset (Albano, Knox, & Barlow, 1995; March & Leonard, 1996). Hence, younger samples tend to have a greater proportion of boys, which equalizes as sample age approaches adolescence. While clinical samples have found OCD to be more common among European American than African American children, epidemiological data suggest there is no difference in prevalence across ethnic groups or geographic regions (Rasmussen and Eisen, as cited in March & Leonard, 1995)

Articles

Geller, D., Biederman, J., Jones, J., Park, K., Schwartz, S., Shapiro, S., & Coffey, B. (1998). Is juvenile obsessive compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature. Journal of the American Academy of Child and Adolescent Psychiatry, 37(4), 420-427.

These authors contend that determining whether juvenile OCD is continuous, discontinuous, or a more severe form of adult OCD is critical to developing an etiologic understanding of the disorder as well as providing appropriate treatment. Hence these authors reviewed 43 articles on juvenile OCD, in order to analyze correlates of juvenile OCD and contrast these with correlates of adult OCD. They reasoned that similarities in correlates would indicate that juvenile OCD is part of the same developmental continuum of adult OCD, while differences in these correlates would provide evidence that they are discontinues disorders. Correlates examined included: age at onset, gender distribution, symptom phenomenology, psychiatric comorbidity, neurological and perinatal history, family psychiatric history, cognitive and neuropsychological profiles, treatment, and outcome. The authors present a careful analysis of these correlates. They conclude that differences between adult OCD and juvenile OCD correlates strongly suggest that juvenile OCD significantly differs from adult OCD. They emphasize the need to further investigate their conclusion as it suggests that age of onset may be critical variable in identifying developmental subtypes of OCD.

Henin, A., & Kendall, P. C. (1997). Obsessive-compulsive disorder in childhood and adolescence. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical psychology (pp.75-131). New York: Plenum Press.

     This book chapter provides a comprehensive literature review of Obsessive-Compulsive Disorder as it manifests in children and adolescents. The authors begin with a definition of OCD, followed by a description of the similarities and differences between adult and children in the clinical presentation of the disorder.   In the discussion of prevalence rates for OCD, the authors observed that recent epidemiological results indicate that OCD is much more common in children and adolescents than once believed. It was also noted that prevalence rates varied across studies and that these variations may be due to: (a) differences in the criteria and measures employed; and (b) possible underreporting of OCD symptoms by youth.   Onset for childhood OCD was reported to occur between the ages of 8 and 11 in the majority of cases, and a large percentage of adults with OCD report that the symptoms began in childhood.   Onset of OCD symptoms was reported in the literature to vary between sudden appearance and a more gradual emergence. Several studies attempted to identify precipitating factors of OCD, with conflicting results. The authors state that accurate information regarding onset of the disorder is difficult to obtain since retrospective recall cannot always be relied on. Regarding the course of OCD, there is evidence to suggest that children with an early-onset (prior to age 7) may present with symptoms that are more “unusual”. A study by Hanna (1995), may have further found an interaction effect between age of onset and gender on symptom severity, wherein boys with an early onset and girls with a late onset exhibiting more severe symptomatology.
     The authors look at the various methods of assessment used to evaluate OCD. They review the literature on structured interviews, rating scales, and various inventories. In the next section, the various theoretical models of OCD are explored. These theoretical models include: cognitive; behavioral; and neurobiological. The authors spend considerable time outlining the recent neuroanatomical findings that have emerged in the literature. In the last section, the authors focus in on the various treatments currently being used with children experiencing symptoms of OCD. Treatments reviewed include behavioral therapy, specifically exposure and response prevention, and pharmacological treatments that utilize antidepressants with specific serotonin uptake blocking effects.
     The authors conclude by stating that the study of OCD in children and adolescents is still in its infancy. They observe that there are still considerable gaps in the literature, especially around developmental issues in information-processing models of child psychopathology. They call for future research that uses group-comparison designs and the development and implementation of a consistent battery of assessments to better evaluate OCD.

March, J., & Leonard, H. (1996). Obsessive-compulsive disorder in children and adolescents: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 35(10), 1265-1273.

The authors provide an excellent review of the literature focusing on child and adolescent obsessive compulsive disorder. Utilizing the perspective of the American Board of Psychiatry and Neurology, the authors summarize the basic knowledge base expected of child and adolescent psychiatrists. Specifically, the following areas are addressed: epidemiology; diagnosis (based on DSM-IV); phenomenology of symptoms; age and gender; developmental and contextual factors; comorbidity; etiology, with a focus on a neurobehavioral explanation for OCD; assessment; treatment, emphasizing the use of combined cognitive-behavioral therapy and pharmacotherapy; natural history of the disorder; and predictors of outcome. The authors highlight the unfortunate underdiagnosis of child and adolescent OCD, indicating that although current treatments will not cure OCD, treatment is critical in allowing children to “resume a more normal trajectory.” In addition to the extensive reference list provided, the authors specifically note six articles they consider to be seminal pieces in this field of research.

Swedo, S. E., Leonard, H. L., & Rapoport, J. L. (1997). Childhood-onset obsessive compulsive disorder. In D. J. Stein & M. Stone (Eds.), Essential papers on obsessive-compulsive disorder (pp. 361-372). New York: New York University Press.

     This book chapter discusses the clinical presentation of childhood-onset obsessive-compulsive disorder based on two clinical samples. The first sample was obtained from clinical interviews of 70 children and adolescents who participated in treatment studies at the Child Psychiatry Branch of the National Institute of Mental Health, along with 18 youth from a New Jersey epidemiologic sample. The ages of the participants ranged from 6 to 18 years, and each had displayed OCD symptoms for a least one year.
     The researchers found that the majority of the children presented with both obsessions and compulsions, with only 4% of the youth being classified as “pure obsessives”, and a slightly higher percentage being “pure ritualizers”. Of the “pure ritualizers” group, most of the children were very young (ages 6 to 8), and denied having any thoughts preceding their rituals.   The most common OCD symptom found in the combined samples was that of excessive washing (approximately 85%), followed by repeating rituals (over 50%), checking rituals (46%), and obsessional symmetry or ordering (17%). Other common OCD symptoms included aggressive or sexual images (4%) and “scrupulous adolescents” (e.g., concerns about going to hell if they did not act in the right way-13%). The research also found that in 95% of the sample, the rituals and obsessions vary over time, indicating that a child may abandon a particular obsession or compulsion and replace it with a new one. The authors note that often it is difficult for parents and mental health providers to detect OCD symptoms due to the secrecy that is often displayed by children and adolescents with this disorder.
     It was found that only 26% of the children had OCD as their sole diagnosis. Comorbid diagnoses most frequently observed were: depression (39%); simple phobia (17%); social phobia (16%); separation anxiety disorder (7%); developmental disabilities (24%); oppositional defiant disorder (11%), and ADHD (10%). The fact that Tourette’s syndrome was considered an exclusionary criterion for the NIMH study, resulted in no comorbidity information regarding that disorder. However, the researchers did find during the 7-year follow-up of the NIMH sample, that 12% of the children met the criteria for Tourette’s syndrome.
     The authors dedicate a portion of the chapter to the discussion of treatment modalities and their rates of success. The various treatments considered include: pharmacotherapy; family therapy; group therapy; and behavioral therapy.
     The chapter ends with an examination of the results from a 7-year follow-up of the original NIMH sample.   They found that 70% of the youth were still taking medication for their OCD symptoms. Less than half of this group still met the criteria for OCD, and 80% had improved from baseline. The improvement ranged from 15% for “minimally improved”, 30% for “much improved”, and 43% for “very much improved”.   The authors observe that although pharmacotherapy and behavioral therapy had improved many of the OCD symptoms these youth had presented with, the disorder still remains chronic.

Conclusion

Despite the fact that juvenile Obsessive-Compulsive Disorder has been well-researched during the past two decades, there still remain questions such as: Why does OCD continue to be underdiagnosed? Why is OCD often confounded with other mental health disorders? What is the precise etiology underlying this disorder? and Is juvenile OCD part of a developmental continuum of the adult-form of the disorder or is it a separate developmental subtype? Presently the incidence rate for children and adolescents is between 2% and 4%, and if left untreated, these juveniles can experience severe impairment in their social, academic, and personal lives. While treatment cannot “cure” OCD altogether, appropriate treatment can greatly alleviate the symptoms of the disorder, permitting return to normal developmental trajectories.

References

Adams, G. B., Waas, G. A., March, J. S., & Smith, M. C. (1994). Obsessive compulsive disorder in children and adolescents: The role of the school psychologist in identification, assessment, and treatment. School Psychology Quarterly, 9, 274-294.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.

Berg, C. J., Rapoport, J. L., & Flament, M. (1986). The Leyton Obsessional Inventory-Child Version. Journal of the American Academy of Child Psychiatry, 31, 84-91.

Flament, M.K., Rapoport, J.L. Berg, C.J., et al. (1988). Obsessive-compulsive disorder in adolescence: An epidemiological study. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 764-771.

Geller, D., Biederman, J., Jones, J., Park, K., Schwartz, S., Shapiro, S., & Coffey, B. (1998). Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature. Journal of the American Academy of Child and Adolescent Psychiatry, 37(4), 420-427.

Jenike, M.A. (1989) Obsessive-compulsive and related disorders: A hidden epidemic. New England Journal of Medicine, 321, 539-541.

Leonard, H. L., Swedo, S. E., & Lenane, M. C. (1993b). A 2-to 7-year follow-up study of 54 obsessive-compulsive children and adolescents. Archives of General Psychiatry, 50, 429-439

March, J. S., & Leonard, H. L. (1996). Obsessive-compulsive disorder in children and adolescents: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 35(10), 1265-1273.

Scahill, L., Riddle, M., McSwiggen-Hardin, M., & Ort, S. I. (1997). Children’s Yale-Brown obsessive compulsive scale: Reliability and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36(6), 844-852.

Silverman, W. K., & Nelles, W. B. (1988). The anxiety disorders interview schedule for children. Journal of American Academy of Child and Adolescent Psychiatry, 27, 772-778.

Wicks-Nelson, R., & Israel, A. C. (Eds.). (1997). Behavior disorders of childhood (3rd ed.). Upper Saddle River, NJ: Prentice Hall.

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Etiology

     There are a number of theories in the current psychological literature that attempt to explain the etiology, or cause, of obsessive-compulsive disorder. These theories can be divided into three general categories: 1) the biological perspective; 2) the cognitive-behavioral perspective; and 3) the developmental perspective. Each of these perspectives views OCD through a unique etiological lens and sheds light on a specific dimension of the disorder.
     Current research has found strong evidence in support of a biological basis for OCD. This evidence comes from studies that have looked at neurological components as well as genetic factors. The neurological dysfunction models have evolved from studies finding: (1) an association between the obsessions and compulsions exhibited by individuals with OCD and the tics, vocalizations, and obsessive thoughts found with other neurological disorders such as Tourette’s Syndrome, Postencephalitic Parkinson’s Disease, and Sydenham’s Chorea (Wise & Rapoport, 1898); (2) studies that have utilized brain imaging techniques have found structural brain abnormalities, specifically of the circuits that link the basal ganglia to the cortex, in patients with OCD (Luxenberg et al., 1988; Swedo et al., 1989a; Swedo et al., 1989b, as cited in Wicks-Nelson & Israel, 1997); (3) pharmacological treatments utilizing serotonin reuptake inhibitor (SRI) medications reduce obsessive-compulsive symptoms. Further evidence that suggests a biological basis for OCD are genetic studies that find higher concordance rates of OCD in first degree family members and twins than in the general population.
     The cognitive-behavioral perspective implicates distorted cognitions as the cause of the obsessive thoughts exhibited in individuals with OCD. The compulsive behaviors that often follow the obsessive thoughts are seen as attempts on the part of the individual to neutralize the “bad thought” and to make things right again.
     The developmental approach, as described by Bolton (1997), considers both the neurobiological and the cognitive-behavioral theories and addresses how OCD symptoms might develop or change over time. Within this perspective, a “multitude of interdependent and reciprocal influences, mechanisms, and processes [are clearly understood to be] involved in the etiology and course of child psychopathology” (Mash and Dazois, 1996).

1. Biological

Billett, E. A., Richter, M. A., & Kennedy, J. L. (1998). Genetics of obsessive-compulsive disorder. In R. P. Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive-compulsive disorder: Theory, research, and treatment (pp. 181-206). New York, NY: Guilford.

This chapter summarizes evidence consistent with a genetic explanation for the development of OCD. The authors review twin and family studies that were conducted with OCD populations. This includes a review of all published twins studies in the world literature (14 studies in all), which date back to 1936. In examining concordance rates for OCD in monozygotic:dyzygotic twins, the authors report a ratio of 2:1. This ratio is consistent with genetic etiology involving a small number of genes. In their review of the family studies, the authors point to the higher rates of OCD in first degree relatives of OCD probands and to the increased rate of tic disorders in relatives of OCD probands (4.6%), when compared to relatives of controls ( 1%). Again, the authors interpret these finding as evidence of genetic etiology of OCD. In addition, the authors review molecular genetic strategies currently available for the study of OCD etiology (linkage analysis, association studies focusing on “candidate genes” in the seratonin and dopamine system). However these studies are characterized as producing indefinite results. The authors conclude their review by identifying the studies reviewed as “valuable beginnings” and calling for studies with larger samples and more specific diagnoses which differentiate clinical phenotypes.

Gross, R., Sasson, Y., Chopra, M., & Zohar, J. (1998). Biological models of obsessive-compulsive disorder: The seratonin hypothesis. In R. P. Swinson; M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive-compulsive disorder: Theory, research, and treatment (pp. 141-153.). New York, NY: Guilford.

These authors review research supporting the hypothesis that abnormality in the serotonin system is the underlying pathophysiology of OCD. They review studies from three different lines of research. The first and strongest line of evidence is based on studies which examine and document the efficacy of antiobsessional medications as a function of
serotonin reuptake inhibition. The authors note that OCD differs from other anxiety disorders in that persons with OCD respond most positively to medications possessing a serotonergic profile. The second line of research focuses on studies of peripheral markers of the serotonergic system function ( e.g.: cerebrospinal fluid studies and blood studies). While these studies provide some evidence for the involvement of the seratonin system, the findings are far from consistent and the sample sizes are typically small. Thus, this second line of research fails to present a consistent line of evidence. Finally the authors review pharmacological challenge studies with serotonergic agonists or antagonists using agents such as L-tryptophan, fenfluramine, and meta-chlorphenylpiperazine. The authors conclude that there is a lack of convergence across these studies, and that although the drug response profile studies do provide strong evidence for the involvement of the serotonergic systemic OCD etiology, the mechanism for this involvement remains inconclusive.

2. Cognitive-Behavioral

Salkovskis, P. M. (1997). Obsessional-compulsive problems: A cognitive-behavioral analysis. In D. J. Stein, & M. S. Stone (Eds.), Essential papers on obsessive-compulsive disorder (pp. 218-256). New York: New York University Press.

The author of this article proposes that the obsessions and compulsions exhibited by individuals diagnosed with OCD can be understood when viewed within a cognitive-behavioral framework that is largely based on Beck’s cognitive model (1967,1976). The author specifically examines how obsessional thoughts fit within the cognitive model and how they are associated with the “negative automatic thoughts” described by Beck. Salkovskis also draws on the observations of Rachman (1978), who states that negative intrusive thoughts (obsessions) are a relatively “normal” phenomenon experienced by most people at one time or another. Since “everyone” experiences intrusive negative thoughts from time to time, why is it that some people develop OCD and others don’t? It is proposed that obsessive thoughts may serve as stimuli which provoke or elicit a certain type of negative automatic thought. The author suggests that the intrusive thoughts provoke ideas about being responsible for damage or harm coming to oneself or to others. The thoughts revolve around personal responsibility and blame. The cognitive distortion exhibited by individuals with OCD relates to the inflated belief that they may, in fact, be to blame for serious harm coming to someone. Most “normal” individuals do experience negative or disturbing thoughts from time to time, however, they do not make the same attributions as individuals with OCD. Persons with OCD believe that if they do not neutralize the behavior then it is the same as wanting to carry out the thought or wanting it to happen to oneself or others. This belief is followed by the conviction that one should, and can, exercise control over one’s thoughts. The compulsion then serves as a neutralizer of the bad thought regarding personal responsibility or blame. Neutralization can be explained as attempts to avoid or reduce the possibility of being responsible for harm to oneself or others. Neutralizing reduces the discomfort of the automatic thought which increases the liklihood that it will be utilized again to cope with stress or anxiety. Neutralization is also consistently followed by non-punishment and this may validate the person’s distorted beliefs that blame would have befallen them or others if they hadn’t acted. Lastly, the act of neutralization itself is a powerful and unavoidable triggering stimulus. Salkovskies’ model also accounts for seemingly “senseless” compulsions that do not seem to have any relation to the obsessive thought nor the automatic thought by proposing that the initial neutraliztion of the automatic thought was so effective that the individual has found a way to completely avoid its effects. Individuals with OCD also tend to seek reassurance from friends and family members. The author states that this reassurance-seeking behavior provides the individual with a way of “spreading the responsibility” by making sure others know the content of their worries. The author concludes by calling for validation and empirical study of his proposed theory.

3. Developmental

Bolton, D. (1996). Annotation: Developmental issues in obsessive-compulsive disorder. Journal of Child Psychology & Psychiatry and Allied Disciplines, 37(2), 131-137.

     This article explores current models of Obsessive-Compulsive Disorder with an emphasis on developmental themes. The author notes that OCD symptoms have been, on the one hand, conceptualized as normal cognitive development gone awry, while on the other side, the symptoms are often associated with known or suspected cerebral disorders. The author examines these competing theories using a developmental approach.
     When viewing OCD symptoms within a cognitive developmental framework, it has been observed that obsessions and compulsions have components that are similar to normal childhood superstitions and rituals. The difference being that obsessions and compulsions are often longer in duration, are experienced as more distressing, and interfere with normal functioning. It has also been observed that young children often engage in “magical thinking”, wherein the distinction between mental events and events based in reality are blurred. Magical thinking, which is considered a pre-rational style of thinking, allows children to experience a feeling of control over events that matter to them, while at the same time alleviating anxiety and feelings of helplessness that can lead to inaction. Superstitions and rituals can be used when rational belief and action do not explain environmental outcomes. Although the superstitious belief or ritual does not change the outcome, they can reduce anxiety, the sense of helplessness, and the despair that may follow from this perceived lack of control. Therefore, a child may adopt magical thinking and employ ritualistic action to control seemingly uncontrollable events. This magical thinking may account for the “large-scale” and “fantastical” quality of the symptoms.
      The neurological deficit model takes a different approach to understanding the symptoms of OCD. Research has found associations between OCD symptomatology and cerebral disease. These associated neurological problems include: structural abnormalities in the brain, biochemical abnormalities; and similar symptoms occurring in individuals with tic disorders; encephalitis lethargica; and occasionally, head injuries. The author states that models seeking to explain OCD within a neurological deficit framework have done so by combining forces with ethological theory. Ethological theory proposes that some OCD behaviors are displacement behaviors. These displacement behaviors are characterized as fixed action patterns that are carried out in the absence of normal releasing stimuli, usually in situations of drive conflict or frustration. Under normal circumstances these displacement behaviors are triggered by a releasing stimulus, and include pecking, grooming, hoarding, and digging. The implication is that a neurological abnormality or vulnerability set off these displacement behaviors.
      The author suggests that the neuroethnological approach can better explain OCD symptomatology when combined with a developmental psychological approach and proposes that “Compulsions are displacement behaviors repetitively triggered by pathological neural activity, with obsessions being something like a post hoc rationalization of this senseless motor output.” The author concludes by stating that a developmental approach is needed in order to fully understand any theoretical model of OCD, and that the ability of current models to inform treatment decisions remains uncertain.

II. Developmental Perspective

What is a developmental approach in general?

In general, the developmental approach is a broad perspective which utilizes general developmental principles, norms, and findings while integrating various theories or perspectives in order to study the dynamic process of change over the life span (Wick-Nelson and Israel, 1996). The developmental approach informs contemporary perspectives of childhood psychopathology in a number of ways: First, the study of normal development provides a framework for understanding the general course of structural and functional change processes over the life-span (Wick-Nelson and Israel, 1996). Hence, from a developmental approach, child psychopathology can be evaluated in reference to normal development. Second, within the developmental perspective, the change process which occurs over the life-span is conceptualized as the result of the continuously evolving dynamic process of transactions among several variables. Therefore, within this perspective, a “multitude of interdependent and reciprocal influences, mechanisms, and processes [are clearly understood to be] involved in the etiology and course of child psychopathology” (Mash and Dazois, 1996). Generally, the variables involved in both normal and abnormal development can be classified as either: genetic and biological predispositions, or psychosocial characteristics (Wick-Nelson and Israel, 1996). In terms of understanding the etiology of OCD, the divergent lines of etiological research summarized above certainly provide evidence consistent with the multi-factor theory suggested by the developmental perspective.

Additionally, within this developmental perceptive, the concept of “developmental pathways” has evolved as a metaphor for the series of “behavioral continuities and transformations ...[which] summarize the probabilistic relationship between successive behaviors” (Loeber, as cited in Mash and Dazois, 1996). This concept of developmental pathways is closely tied to the concepts of equifinality and mulitfinality. Equifinality refers to the idea that multiple pathways can lead to the same outcome. Mulitfinality refers to the ideas that similar pathways can result in a variety of different pathways.
In reference to OCD, the concept of equifinality is useful in terms of understanding the various lines of research which suggest that: (1) pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections or PANDAs, a subtype of pediatric OCD onset, arises “in the context of A [Beta]-hemolyptic streptococcal infection (GABHS)” (March & Leonard 1996); (2) OCD may be linked to seratonin system abnormalities (Gross, Sasson, Chopra, & Zohar, 1998); (3) that frontal lobe and basal ganglia abnormality may be involved in the development of OCD, and; (4) there may be a cognitive developmental pathways to OCD (Bolton, 1996). Thus, these various proposed divergent lines of research illustrate the possibility that there may indeed be a number of different pathways to OCD ( equifinality).

III. Web Links for Child/Adolescent Obsessive-Compulsive Disorder

1) http://www.nimh.nih.gov/publicat/ocd.htm

This web site, developed by the National Institute of Mental Health, gives a comprehensive overview of Obsessive-Compulsive Disorder in both adults and children. The site provides the reader with knowledge regarding the symptoms, causes, and treatments of OCD, along with information on where and how to obtain help for the disorder. The site also acknowledges the concerns that family members of OCD sufferers may have and gives tips on how to cope with and support those persons experiencing OCD symptoms. Lastly, the site provides numerous resources, in the form of organizations and books available, on understanding and dealing with obsessive-compulsive disorder.

2) http://www.ocfoundation.org/ocf_0006.htm

This web site was created by the Obsessive-Compulsive Foundation, a non-profit organization that assists individuals, family members, and professionals who are dealing with OCD. The site does a thorough job in explaining the ways that OCD manifests in both children and adults, as well as the possible causes underlying the disorder. What is most impressive about this site is the detailed information given in each subsection. For example, when the authors are discussing the treatment options available for OCD clients, they give specific information on what the various treatment approaches consist of and what both the client and family members can do to facilitate the process. The site also provides a listing of OCD support groups across the country that is updated on a regular basis. In addition, visitors to the web site can access bulletin boards, available reading materials, newsletters, and conferences that focus on OCD. Information is presented in a manner that is understandable to both lay persons and professionals. The site provides hope and support to those seeking concrete ways of living with OCD.

3) http://www.ocdhope.com

At first glance this web site appears to be an advertisement for the therapist who has created the page, however, once the reader delves into the content of the site, its usefulness and accessibility become apparent. Along with information regarding symptomatology, etiology, and treatment of OCD, the site also provides a section on Frequently Asked Questions (FAQ) that is both informative and comforting. The FAQ section explores in depth the various treatment approaches to OCD, the role that family members play in treatment, and the common fears that individuals may have regarding the process. The site also has a section on self-help principles that address the chronic nature of OCD and the ways that individuals and family members can remain hopeful and functional despite the disorder.

4) http:/neuron.med.wayne.edu/OCD/index.htm

This web site was developed by the Wayne State University OCD Clinical Research Program. The site provides information on OCD that is useful to both the professional community and the lay public. There is a comprehensive description of what OCD is and how it can impact the lives of both individuals and family members. The site also provides information on the two most commonly recognized approaches used in treating OCD; medication and behavioral therapy. There is a section that explores current research being conducted in the area of obsessive-compulsive disorder, as well as a more advanced section that explores recent medical findings regarding the origin of OCD symptomatology. Several recent article abstracts are also provided, along with links to other OCD web sites.

5) www.duke.edu/~vunico/pcaad/#about

This is the website for Duke University's Program in Child and Adolescent Anxiety Disorders (PCAAD) headed by Dr. John March (a prominent expert on anxiety disorders in children). They provide general information on the full range of anxiety disorders as well as specific information regarding OCD. Excellent resources for OCD are provided including: a general introduction and definition of OCD, DSM IV criteria, information regarding differential diagnosis, research updates and links, and 5 top-quality external website links about OCD. This site is written in clear understandable language and contains information useful to both professional and lay-persons. A notable feature of this web site is it’s complete availability in Spanish. This feature may be particularly useful for those seeking a patient/family handout in Spanish, as this too can be accessed within this website.

6) www.fairlite.com/ocd

“The Obsessive Compulsive Disorder Webserver.” This is an amazingly complete and easily accessed website. The home page accesses seven valuable links to the following categories: a) medical --provides a definition of OCD, complete with DSM IV symptoms and descriptions of these; b) overview--provides a detailed explanation of OCD and the various sub-categories (checker, hoarders, etc.) written in language which is accessible to the general public; c) articles--provides links to related articles about OCD. Notably, there is an excellent article written specifically for school personnel which included various recommendations for educational accommodations which can be made in the school setting for children with OCD; d) news--provides links to a variety of services which might benefit those interested in OCD including a chat room for OCD, support for support people, and other exceptionally useful OCD-related websites; e) personal--provides links to personal resources such as “inspirational quotes to help deal with OCD,” a teen OCD mailing list, places to contact if you can not afford medication; f) board--accesses a bulletin board focusing on OCD which allows users to access information and support from others persons with OCD; g) books--provides access to print and audio media useful to those interested in for professional or personal reasons. This website is useful for anyone wanting access to a “full service” website on OCD, as this site provides information and links to sites useful to professionals, people with OCD, family and friends of people with OCD, and those simply interested in learning more about OCD.

IV. Conclusion

The theories regarding the origin or cause of Obsessive-Compulsive Disorder currently fall into three general categories: the biological perspective; the cognitive-behavioral perspective; and the developmental perspective. Each theory has evidence to support its view of the etiology of OCD. It should be noted, however, that no single theory (to date) can completely account for the development and course of OCD in all individuals. It may be that each of the three perspectives represent different dimensions of OCD, and that the interplay between the biological, the cognitive, and development cannot be sifted apart.

References

Albano, A. M., Knox, L. S., & Barlow, D. H. (1995). Obsessive-compulsive disorder. In A. R. Eisen, C. A. Kearney, C. A., & C. E. Schaefer (Eds.), Clinical Handbook of anxiety disorders in children and adolescents (pp. 283-316). New Jersey: Jason Aranson, Inc.

Billett, E. A., Richter, M. A., & Kennedy, J. L. (1998). Genetics of obsessive-compulsive disorder. In R. P. Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive-compulsive disorder: Theory, research, and treatment (pp. 181-206). New York, NY: Guilford.

Bolton, D. (1996). Annotation: Developmental issues in obsessive-compulsive disorder. Journal of Child Psychology & Psychiatry and Allied Disciplines, 37(2), 131-137.

Jenike, M.A. (1989) Obsessive-compulsive and related disorders: A hidden epidemic. New England Journal of Medicine, 321, 539-541.

Mash, E. J. & Dozois, D. (1996) Child psychopathology: A developmental-systems perspective. In E. Mash, R. Barkley, (Eds): Child psychopathology (pp. 3-60).
New York, NY: Guilford.

Wicks-Nelson, R., & Israel, A. C. (Eds.). (1997). Behavior disorders of childhood (3rd ed.). Upper Saddle River, NJ: Prentice Hall.

Wise, S. P., & Rapoport, J. L. (1997). Obsessive-compulsive disorder: Is it basal ganglia dysfunction? In D. J. Stein, & M. S. Stone (Eds.), Essential papers on obsessive-compulsive disorder (pp. 260-276). New York: New York University Press.

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ASSESSMENT

According to Kamphaus and Frick (1996) clinical assessment of children involves “determining whether the child’s psychological functioning is pathological and in need of treatment [as well as] determining the types of pathology present.” In order to make these determinations, the clinician needs to gather, evaluate, and interpret information about the child. Because classification system greatly influence the clinician’s evaluation and interpretation of information gathered, it is critical to base the assessment process on a model which is consistent with child and adolescent populations. Developmental psychopathology provides such a model. This perspective includes the following considerations: knowledge of developmental patterns and processes and their effect on emotional and behavioral functioning, an understanding of the stability of behaviors over time and across situations and contexts (e.g. at home, at school, with peers), awareness of the need to evaluate multiple domains of functioning (e.g. emotional, behavioral, learning, and social domains) (Kamphaus and Frick, 1996) . The following annotated bibliographies focus on articles which describe this comprehensive process, as it applies to the assessment of Obsessive Compulsive Disorder (OCD) in children.

The assessment of Obsessive-Compulsive Disorder in children and adolescents can be challenging and complex. One reason for this is the high incidence rates of co-occurring mental health disorders with OCD. Obsessive-Compulsive Disorder can be easily overlooked or misdiagnosed when disorders such as Tourette’s Syndrome, Anorexia Nervosa, or Generalized Anxiety Disorder are also present. A second reason why assessment can be difficult is due to the fact that children and adolescents are often secretive and embarrassed about their OCD symptoms. The disorder can often be active for several years before it comes to the attention of parents or family members. Finally, the course of OCD changes over time and can manifest in different ways depending on the context. It is therefore necessary to use a multi-method and multi-informant approach to assessment. Assessment should be understood as a process of information gathering, rather than a one-time endeavor. For example, some assessments, such as a clinical interview, may only be utilized at the beginning of treatment, while self-monitoring methods would be implemented on a weekly or even daily basis. The process of assessment can include such strategies as reviewing the child’s medical condition, detailing thoughts and behaviors the child is experiencing, and observing family dynamics. What is important to remember is assessment should take in the complete biological, developmental, and environmental picture of the child and how they are currently functioning in each of these areas.

Annotated Bibliographies

1. American Academy of Child and Adolescent Psychiatry (1998). Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37(10), (Suppl. Oct.) 27S-45S.

Based on an extensive literature review and expert consultation, this article outlines a set of practical guidelines for the assessment and treatment of OCD in children and adolescents. In addition to assessment and treatment guidelines, the article reviews epidemiology, details descriptions of clinical presentation, co-morbidity (with mood disorders, tic disorder, temperamental, regulatory, and neuropsychological difficulty, pervasive developmental disorders, trichotillomania, eating and body image disorders, and medical conditions). In terms of the treatment guidelines, the authors focus on the two most well supported treatment approaches: cognitive behavior therapy and medication (by serotonin reuptake inhibition). The assessment guidelines presented include: the importance of comprehensive evaluation of development and psychosocial functioning through a multi-methods/multi-informant approach; discussion of the need to distinguish between developmentally appropriate childhood rituals and pathological rituals; the need to evaluate the context and degree of distress associated with obsessions and compulsions, identifies appropriate assessment instruments, discusses co-morbidity symptoms to be alert for, the need to determine family history of OCD and tic related disorders and specifically the need to include a throat culture and other lab analysis in order to determine whether a GABHS infection may be involved in the development of OCD. While this article’s assessment model clearly overlaps with the general recommendations found through out the literature, this article emphasizes the biological/genetic/neuropsychological assessment approach

2. Albano, A. M., Knox, L. S., & Barlow, D. H. (1995). Obsessive-compulsive disorder. In A. R. Eisen, C. A. Kearney, C. A., & C. E. Schaefer (Eds.), Clinical Handbook of anxiety disorders in children and adolescents (pp. 283-316). New Jersey: Jason Aranson, Inc.

     This chapter begins by describing the phenomenology of obsessive-compulsive disorder in children. The authors provide information regarding age of onset, prevalence rates, and the often chronic nature of the disorder. Comorbid psychiatric disorders are reported to occur in 62-74% of children and adolescents diagnosed with OCD. The diagnoses most commonly observed include: anxiety disorders, tic disorders; Tourette’s, and mood disorders. The high incidence of other co-occurring disorders can make differential diagnosis in children and adolescents complex. The authors, therefore, recommend that the clinician use a number of assessment measures in to evaluate the child and family system.
     The assessment battery begins with a structured diagnostic interview that can be used to gather information from both the child and the parents.   The Anxiety Disorders Interview Schedule for Children and Parents (ADIS-C/P, Silverman and Nelles, 1988), is recommended due to its ability to differentiate between the various anxiety, affective, and externalizing disorders of childhood. The child is then administered the Leyton Obsessional Inventory-Child Version (LOI-CV; Berg et al., 1986), which indicates the types of obsessions and compulsions the child is experiencing as well as their perceived resistance in fending off the intrusive thoughts and behaviors.   The therapist then compiles a Obsessive-Compulsive Hierarchy that consists of the child’s fear cues. These fear cues include both internal and external cues, along with their specific consequences, avoidance behavior, and rituals. The child then rates each of the symptoms on a subjective scale ranging from 0-8 (SUDS rating). The ten symptoms identified on the Obsessive-Compulsive Hierarchy then become the focus of the treatment interventions. Children are also encouraged to keep a daily diary that documents all OCD symptoms experienced, what they were thinking at the time, how they felt physically, and what they did. The parents keep a similar diary in which they record what happened and how they responded. Finally, the family is asked to reenact an “anxiety-provoking” scenario in the presence of the therapist. The interaction is videotaped and then replayed and discussed with the family in order to uncover family communication patterns.
     The authors next outline the behavioral treatment program implemented in their clinic. The method utilized is Exposure and Response Prevention (ERP). ERP consists of prolonged exposure to the child’s specific fear cues, combined with blocking of the ritualistic responses.
     The last section of this chapter follows the treatment course of two children diagnosed with OCD.   The first case involves a child with “typical” OCD symptomatology, while the second case concerns a child with more severe symptoms and several comorbid diagnoses. Each child is treated using the aforementioned behavioral treatment program and in both cases the children’s symptoms are substantially reduced.
     The authors conclude by stating that clinical trials will be needed to prove the efficacy of their treatment approach.

3. Francis, G., & Gragg, R.A. (1996). Childhood obsessive compulsive disorder. Thousand Oaks, CA: Sage Publications.

This chapter provides detailed information regarding the assessment of children and adolescents with obsessive-compulsive disorder. The authors stress the importance of “gathering information from multiple sources across different settings using a variety of methods”. It is recommended that the clinician begin the assessment process by gathering information from both the child and their parents using some type of structured clinical interview. The next step in the assessment process utilizes clinician-rated instruments. Global symptom rating scales such as the NIMH Global Obsessive-Compulsive Scale (NIMH-OC; Insel et al., 1983) or the O-C Rating Scale (Rapoport, Elkins, & Mikkelsen, 1980) are discussed. Another clinician-rated scale which assesses the severity of symptoms is the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS; Goodman et al., 1986; Hardin et al., 1991). The authors report on two self-report questionnaires; the Maudsley Obsessional-Compulsive Inventory (MOCI; Hodgson & Rachman, 1977) and the Leyton Obsessional Inventory-Child Version (LOI-CV; Berg, Rapoport, & Flament, 1986), and remark that the LOI-CV is the instrument of choice. Various self-monitoring approaches are examined that allow for the gathering of information regarding the frequency and severity of OCD symptoms. Self-monitoring is the process of recording the presence of a thought or behavior and then rating the level of discomfort associated with them. Self-monitoring methods include narrative descriptions, mechanical counting devices, and data sheets focusing on target behaviors. Lastly, the authors note that behavioral observation can be helpful when children are secretive about their symptoms or are unable to communicate clearly what they are thinking and feeling. Behavioral observation can be conducted during the initial intake interview or in natural settings, such as the child’s home or school. Observational data can provide a more thorough understanding of the context and content of symptoms. The authors conclude by stating the three goals of assessment: (1) determining a diagnosis, which includes ruling out other diagnoses and identifying comorbid disorders; (2) functional analysis of the OCD symptoms; and (3) monitoring the clinical course of the disorder and efficacy of the treatment.

II. DEVELOPMENTAL PERSPECTIVE

When assessing a child or adolescent for Obsessive-Compulsive Disorder it is critical that developmental issues be taken into account. The most basic factor that should be considered when a child is being assessed for OCD, is whether the ritualistic thoughts and behaviors are developmentally inappropriate. It is normal for most children to engage in ritualistic activities at some point in their early development. It is only when the rituals or thoughts start to interfere with the child’s functioning that OCD should be investigated. A second developmental factor is that the child’s cognitive maturity level may affect their ability to report on their inner experience or even be aware of the excessive nature of their symptoms. Therefore, during the assessment process the child may not be able to convey to the clinician the extent to which their symptoms are impacting their functioning. By using a number of different assessment methods such as clinician-rated instruments, behavioral observation, and self-monitoring, the clinician is better able to determine the severity and frequency of the symptoms. Furthermore, if the clinician can gather data from a number of different informants (i.e.: family members, school personnel, and the child), there is again a better likelihood of understanding the child’s current level of symptomatology. Cognitive maturity factors can also present a problem if the assessment measures utilized require developmentally inappropriate responses. For example, a child that is seven years old may not have the language or reading skills to complete a Q-Sort type inventory. The same child may also be unable to use self-monitoring behavior charts due to their complexity. The clinician should be aware of the developmental level of the child and modify the assessment instrument or presentation accordingly.

III. OPTIMAL ASSESSMENT STRATEGY
Consistent with the developmental psychopathology perspective, recent literature (Albano, Knox, & Barlow, 1995; Francis & Gragg, 1996; Henin & Kendall, 1997; Milby, Robinson, & Daniel, 1998; Robinson, 1998) on the assessment of OCD is in general consensus regarding the “optimal assessment strategy”. The literature describes a process which is: (1) multi-modal (utilizes clinical interviews, rating scales, self reports, observations, and self-monitoring instruments), and; (2) multi-informant based (seeking information from key informants such as, parents, teachers, and other family members as well as the child). These assessment characteristics are critical based on the developmental consideration that a child is not likely to be mature enough to give complete information regarding her/his emotional and behavioral state.

According to Milby, Robinson, and Daniel (1998) assessment of OCD has at least four goals. The first goal is diagnosis--determining whether the child meets criteria for OCD diagnosis; ruling out alternative diagnosis; identifying co-morbid disorders (e.g. tics are commonly co-morbid with OCD). The secondary goal is to obtain a functional analysis of the disorder. This involves an analysis of the role of antecedents and consequent variables in symptom mediation to determine whether there are any patterns associated with variations in symptoms. Third, assessment should seek to monitor clinical course and treatment efficacy, allowing for evaluation of treatment and leading to necessary changes in course of treatment. Additionally, monitoring clinical course allows both the child and family to "see" (e.g. through use of charts and graphs) progress over time, thus engendering hope. The fourth goal of assessment should be the evaluation of impairment in functioning within various developmental contexts (family, school, peers). Thus, allowing for assessment of the child's level of adaptive functioning in the larger context in order to identify interventions or support needed beyond treatment for the specific OCD symptoms. Typically, children with OCD do experience disruptions in relationships with peers, teachers, and family members. Such disruptions need to be evaluated for effective treatment planning.

The following is a brief summary of instruments which are compatible with this approach:

Diagnostic Interviews
1. Diagnostic Interview for Children and Adolescents-Revised (DICA-R; Welner, Reich, Herjanic, & Campbell, as cited in Francis & Gragg, 1996).
2. Diagnostic Interview Schedule for Children-Revised (DISC-R; Schwab-Stone et al., as cited in Francis and Gragg, 1996).
3. Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS; Puig-Antich & Chambers, as cited in Francis and Gragg, 1996).
4. The Anxiety Disorders Interview Schedule for Children (K-ADIS; Silverman & Nelles, as cited in Albano, Knox, & Barlow, 1995).
5. Child and Adolescent Psychiatric Assessment (CAPA; Angold, Cox, Predergast, Rutter, & Simonoff, as cited in Henin & Kendall, 1997.
6. Anxiety Disorders Interview Schedule for Children/Parents (ADIS-C/P Silverman & Eisen as cited in Henin & Kendall, 1997.
7. Children's Assessment Schedule (CAS; Hodges, Cools, & McKnew, as cited in Henin & Kendall, 1997)

Clinician-Rated Instruments
1. NIMH Global Obsessive Compulsive Scale (NIMH-OC; Insel et al., as cited in Francis and Gragg, 1996).
2. O-C Rating Scale (Rapoport, Elkins, & Mikkelsen, as cited in Francis and Gragg, 1996).
3. Obsessive-Compulsive subscale of the Comprehensive Psychopathological Rating Scale (CPRS-OC; Asberg, Montgomery, Perris, Schalling, & Sedvall, as cited in Francis and Gragg, 1996).
4. Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS; Goodman et al; as cited in Francis and Gragg, 1996). The most widely recommended instrument.

Self-Report Questionnaires
1. Leyton Obsessional Inventory-Child Version (LOI-CV; Berg, Rapoport, & Flament, as cited in Francis and Gragg, 1996). This instrument can be used to monitor course of symptoms and Tx effects.
2. Spence Children's Anxiety Scale (SCAS; Spence, 1998)

Self-Monitoring
1. Recording presence of behavior in various formats: narrative descriptions; mechanical counting devices; data sheets focusing on target behaviors (Francis and Gragg, 1996).
2. Subjective Units of Discomfort Scales (SUDS; Wolf, as cited in Francis and Gragg, 1996). Allows for recording the level of discomfort associated with their symptoms.

Behavioral Observation
1. Observing the child during the initial evaluation (Francis and Gragg, 1996)
2. Observing how the child completes the assessment tasks (Francis & Gragg, 1996)
3. Observing the child in a natural setting (Francis & Gragg, 1996)
4. BATS--Behavioral Avoidance Tasks (Albano, Knox, & Barlow, 1995)--yield measures of anxiety and a behavioral measure of resistance by measuring: time elapsed until a compulsion is acted on; SUDS; and physiological response to exposure to situations from the child's hierarchy.
5. Parent/Teacher Measurers-- (Albano, Knox, & Barlow, 1995) Parent and teachers can be taught to complete a diary form for each episode of OC behavior they observe. Include: date, time, situation, people present, brief narrative about what they observed, how they responded, how others responded, how the child responded. May be extremely useful in identifying antecedents and consequences.

In general the process should begin with a complete medical, family, and developmental history. Typically this occurs in the context of a general screening. The literature recommends that all practitioners be alert for symptoms of OCD and include some key items which might suggest the need for exploring the presence of OCD. If OCD symptomotology is present, the practitioner should gather data regarding onset and course of symptoms and should proceed to the next level of assessment by utilize a specific OCD screening instrument such as the LOI-CV 20-question screener . Again, if data continue to suggest the presence of OCD, the next level of assessment requires comprehensive OCD assessment instruments such as the CY-BOCS and the LOI-CV 44 question card sort. These instruments provide adequate information for making a diagnosis of OCD.

At this point, a neurological assessment and throat culture are suggested given that: OC symptom may be caused by neurological damage and, a sub-type of OCD is believed to be related to upper respiratory tract infection (King, Leonard, and Marsh, 1998). Once the OCD diagnosis is established, the practitioner will continue to gather data through a multi-modal/multi-informant process, given the above discussed need to establish levels of functioning in the full developmental context in order to develop a comprehensive treatment plan. Finally, assessment will be on-going as a tool for monitoring treatment efficacy (Milby, Robinson, & Daniel, 1998).

IV. CONCLUSIONS

Assessment of Obsessive-Compulsive Disorder in children and adolescents can be complicated and challenging. Factors such as the high incidence of co-occurring disorders in youth with OCD, the developmental level of the child, and the secretiveness associated with the symptoms, can cause the disorder to be misdiagnosed or undiagnosed altogether. Despite these challenges, the research is generally in agreement regarding the use of a multi-modal/multi-informant developmental model. Additionally, clinicians have at their disposal a variety of assessment instruments can be utilized as part of the ongoing process of assessment.

V. WWW SITES

1) http://www.aafp.org/afp/980401ap/eddy.html

This web site, sponsored by the American Family Physicians, offers an informative overview of symptomatology, diagnostic considerations, assessment strategies, and treatment of Obsessive-Compulsive Disorder. The site begins with a presentation of diagnostic criteria, as outlined in the DSM-IV, in a user-friendly chart. The authors then provide epidemiological information such as prevalence rates, age of onset, and chronicity of the disorder, along with a discussion of neurological and psychological causal factors. The authors provide details regarding the presentation of OCD in a clinical setting and what a health care provider should be looking for and what specific questions they can ask to make an accurate diagnosis. The authors write specifically about differentiating OCD from other clinical disorders such as Generalized Anxiety Disorder and Hypochodriasis, Anorexia Nervosa, and Body Dysmorphic Disorder. It is suggested that if OCD is suspected, the clinician can then use a clinical interview and a rating scale, such as the Yale-Brown Obsessive Compulsive Scale to further assess the severity of the symptoms. Lastly, the web site does a nice job of outlining the various treatment options available and they explain the benefits of both behavioral and psychopharmacological approaches. They also provide an easy to read chart which compares the different psychopharmacological medications. Overall, this is an easy to understand web site that provides a lot of useful information.

2) http://www.fairlite.com/ocd/articles/schools.html

This web site contains an article written by Gail Adams and Maria Torchia that focuses specifically on identification and management of Obsessive-Compulsive Disorder in the school environment. The authors begin by stressing the importance of school personnel being able to identify OCD symptoms in children and adolescents. They provide concrete examples of how the various obsessions and compulsions may manifest themselves in the school environment. These obsessions and compulsions may include things like: fears of contamination; fear of harm or illness; and washing or cleaning rituals. The next section gives specific recommendations on what steps school personnel should follow if OCD is suspected in a child. A description of the assessment and referral process is provided, along with the various treatment approaches typically utilized with OCD. The authors do a nice job in explaining how school personnel, especially classroom teachers, can facilitate the treatment process and they provide guidelines on how to manage OCD symptoms in the school setting. The article concludes by discussing Educational services available for children who are diagnosed with OCD.

3) http://www.mentalhealth.com/fr20.html

This site provides a well organized set of information regarding numerous mental health topics. Under the topic of OCD, the reader will find the following categories of information: description of OCD including American and European diagnostic criteria; on-line diagnosis; treatment; updated research; booklets; magazine articles; other web pages; medication and treatment; and internet links to obsessive compulsive and anxiety web sites. For those interested in the assessment of OCD, on-line diagnosis is a wonderful resource. This web page explains what a complete assessment process should include and also provides an interactive questionnaire. This survey allows the web visitor to read and respond to various questions regarding obsessions and compulsions. Based on the respondents answers, an “on-line diagnosis” is provided. This site can be used by clinicians seeking to conduct an on-line assessment of a client, or by individuals seeking to evaluate themselves as a preliminary step to determining whether they should seek profession assistance for obsessive compulsive behaviors.

4) http://www.ocdhelp.org/tools/index.html

This site offers information in four categories: General Information about resources and referrals in California; Education about OCD; Research and Legislation relevant to OCD; and a “Talk-Back” corner where readers can submit questions to the experts. The Education category is of particular interest to those seeking information about OCD assessment instruments. Several assessment “tools” are available including:
1. An OCD screening checklist which includes a test to screen individuals for OCD;
2. DSM-IV diagnostic criteria for OCD;
3. The Yale-Brown Obsessive Compulsive Scale for adults (complete version on line)
4. The Yale-Brown Obsessive Compulsive Scale for children;
5. A link to the National Institute of Mental Health screening test for OCD.
This is a useful site to both clinicians and individual seeking to explore the possibility that they may meet the diagnostic criteria for OCD. The web site visitor is able to respond to the questions contained on these instruments and can receive an on-line diagnosis.

5) http://www.ocdresource.com/whats.html

This site is concise, simple, and clear educational tool for individuals seeking to determine “what’s OCD and what’s not.” The web page presents descriptive information regarding each type of compulsive behavior (e.g. checking/questioning, collecting/hoarding, , cleaning/ washing, counting/repeating, arranging/organizing, etc.). For each type of compulsive behavior the page provides an example of an adult and a child whose behaviors are severe enough to meet diagnostic criteria and an example of an adult and a child whose behaviors are mild enough to be considered “normal.” The examples provided give meaning and context to the words, “excessive” and “severe.” This site is useful to those beginning to learn about OCD and seeking to gain familiarity with “clinical” examples of obsessive compulsive behaviors.

References
Albano A. M.,. Knox L.S, & Barlow, D.H. (1995). Clinical Handbook of Anxiety Disorders in Children and Adolescents (pp. 282-316) . New Jersey: Jason Armson Inc.
American Academy of Child and Adolescent Psychiatry (1998). Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37(10), (Suppl. Oct.) 27S-45S.
Francis, G., & Gragg, R. A. (1996). Childhood obsessive compulsive disorder. Thousand Oaks, CA.: Sage Publications.
Henin, A., & Kendall, P. C. (1997). Obsessive-compulsive disorder in childhood and adolescence. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical psychology (pp. 75-131). New York: Plenum Press.
King, R., Leonard, H., & March, J. (1998). Practice Parameters for the Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 10: Supplement, 27S-44S.
Kamphaus, R.W. & Frick, P.J. (1996). Clinical Assessment of Child and Adolescent Personality and Behavior. Boston: Allyn and Bacon.
Milby, J.B., Robinson, S.L., & Daniel, S. (1998). Obsessive Compulsive Disorders. In R.J. Morris and T.R. Kratochwill (Eds.): The Practice of Child Therapy. Boston: Allyn & Bacon (pp. 5-47)
Robinson, R. (1998). Obsessive-compulsive disorder in children and adolescents. Bulletin of the Menninger Clinic, 62(4), (Suppl. A), A49-A65.
S. Spence. (1998). A measure of anxiety symptoms among children Behavior Research and Therapy, 36, 545-566.
Thomsen, P. H. (1998). Obsessive-compulsive disorder in children and adolescents: Clinical guidelines. European Child and Adolescent Psychiatry, 7(1), 1-11.

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TREATMENT
       Treatment is said to be “the systematic application of remedies to effect a cure” (Roget's, 1988). In selecting an appropriate treatment for OCD, as with any psychological disorder, clients and practitioners need to consider the outcome data of the specific treatment options available in order to determine whether the approach under consideration is likely to “effect a cure.” Currently, within the field of psychology, there is a great deal of attention being given to determining whether outcome data exists to support specific treatment approaches as efficacious in the treatment of particular disorders. Despite this interest in outcome data for distinct treatment approaches, much of the outcome research does not focus on pediatric populations (Wiesz, 1998). However, in the case of child and adolescent OCD, the strong line of evidence available has helped to identify two effective treatment approaches and there is even “expert consensus” on the optimal treatment approach (March, Frances, Carpenter, & Kahn, 1997). Currently, the two main treatment approaches are: Cognitive Behavior Therapy (CBT) and pharmacotherapy. These two treatment approaches are frequently used in combination, as suggested by the expert consensus guidelines.
       Cognitive Behavior Therapy of OCD includes a behavioral component called Exposure Response Prevention (E/RP) as well as a cognitive/educational component which frames OCD as an anxiety disorder over which the child can learn to exercise control (Bolton, 1998). E/RP consists of: (1)exposure to feared stimuli (as identified by the child’s obsessional thoughts) which increases anxiety and provoke compulsions, and; (2) response prevention which focuses on prevention of the compulsive response. Over repeated E/RP sessions, the anxiety associated with the obsession and with not performing the compulsion decreases. The cognitive/educational aspect of CBT involves age appropriate explanations of the disorder and the treatment approach, encouraging and enlisting child-collaboration, contingency management, and most importantly the development of cognitive intervention skills such as strategic “self -talk” and self monitoring. CBT approaches also place importance on considering the relationship between thoughts, behavior, feelings and the child’s functioning in the larger social context. Thus, a critical component of CBT focuses on peer and family interactions as they impact or are impacted by the child’s disorder (Kendall, Marrs, & Chu, 1998). As a result, family therapy is frequently integrated into this treatment approach. Treatment effectiveness of this approach is quite high. CBT and CBT combined with pharmacotherapy have been documented to have significant improvement in 60 to 87% of cases (Bolton, 1998). Additionally, CBT has been shown to have medium and long-term maintenance of gains from treatment as well as reduce relapsed rates in patients withdrawn from pharmacotherapy (Bolton, 1989; March, Frances, Carpenter, & Kahn, 1997).
       In contrast to CBT, pharmacotherapy frames OCD in terms of a “medical model” which characterizes the disorder as a neurological deficit (Bolton, 1998). The obsessions and compulsions are explained as the result of abnormally triggered brain activity (i.e. “brain hiccups”). In group studies of OCD, only the serotonin reuptake inhibitors (Clomipramine, Fluoxetine, Fluvoxamine, Paroxetine and Sertraline ) have been shown to be effective pharmacological agents (Bolton, 1998). March and Leonard (1998) report that pharmacotherapy has a 30-40% “average magnitude of improvement on the YBOCS” (the scale of symptom severity described in the Assessment section above). Despite these improvement rates, these authors noted that in a study of children treated with clomipramine (the best-studied medication in the child/adolescent population) less than 20% fell below the threshold for clinical disorder at the end of clomipramine treatment. Finally, Pigott and Seay (1998) report that treatment gains from pharmacotherapy will be lost after the medication is discontinued. However, after reviewing literature on the life-course of OCD Bolton (1998) suggests that effective E/RP therapy, “during adolescence may obviate the need for long-term maintenance pharmacotherapy.”

Francis, g., & Gragg, R. A. (1996). Childhood obsessive compulsive disorder. Thousand Oaks, CA: Sage Publications.

       This chapter examines the literature on three approaches to the treatment of OCD and how these interventions are applied to work with children and adolescents. The first treatment approach discussed is the psychotherapeutic model of Exposure and Response Prevention (E/RP). Studies indicate that this is the treatment of choice for adults with OCD and that 75% of adults treated with this method show substantial improvement. The authors report that it is difficult to determine whether this treatment model is equally effective with children and adolescents due to the limited number of studies in the literature that focus specifically on this population. Furthermore, the studies that are available for review tend to suffer from numerous methodological problems, such as small sample size, lack of experimental control groups, and poorly defined outcome measures. Despite the lack of empirical evidence for the use of E/RP with youth, the authors recommend that clinicians apply this model as their primary psychotherapeutic intervention. A thorough discussion of the E/RP theory and treatment application follows.
       The second OCD treatment explored was the psychopharmacologic approach. In general, this method involves the use of medications that influence the neurotransmitter system, specifically inhibiting the reuptake of serotonin. The effects of several serotonin reuptake inhibitors (SRIs) have been studied, however, the authors state that Clomipramine (CMI) is the only medication currently approved by the FDA for the treatment of childhood OCD. The authors summarize the various studies that have looked at the effects of CMI in children with OCD and conclude that the literature contain several well-designed studies that provide support for the efficacy of CMI with children. It is also noted, however, that children and adolescents may find the side-effects of CMI difficult to tolerate. The authors recommend that further research be conducted on other SRI medications that result in fewer side-effects and that psychopharmacologic treatments should be used as a first-line treatment only when clients are unwilling or unable to comply with behavioral interventions.
       The third treatment approach discussed is the use of psychosurgery. This procedure involves lesioning of areas of the brain thought to be involved in OCD. Studies on adults who have received this treatment show improvement rates varying from 25% to 84%. The authors state that very little research exists on use of this treatment with children, and they state that this method should only be used as a “last resort” when a patient does not respond to aggressive behavioral and psychopharmacologic interventions.
       The authors next address specific developmental issues that need to be kept in mind when treating children and adolescents with OCD. They offer tips and guidelines on how to modify E/RP to fit the developmental level of the child so that the child can understand and participate in the treatment process. They also provide cautions regarding the potentially overwhelming anxiety a child may feel during the implementation of E/RP and give examples of how a clinician can address these concerns. In regards to use of medications with children, the authors suggest that the therapist work closely with the psychiatrist prescribing the medications and that they attend to the anxiety and misconceptions that may come up for both the child and the parents during this process.
       Lastly, the authors state that the symptoms of OCD often impact the social development of the child and can impair the various systems in which the child is a part (i.e.: their family; school). They suggest that treatment should incorporate these systems as a way to facilitate treatment gains. Specifically, the authors recommend that the parents be trained in operant techniques as a way to assist child in complying with the treatment and that the clinician be cognizant of what role the child plays in the family system. It is also recommended that school personnel be involved in E/RP tasks and homework since OCD symptoms may manifest in that environment as well. The authors conclude by offering information regarding various community resources that family and clients can contact.

March, J. S., & Mulle, K. (1998). OCD in children and adolescents: A cogntive-behavioral treatment manual. New York: Guilford Press.

       This chapter provides an overview of the authors’ manualized treatment protocol for childhood obsessive-compulsive disorder. The chapter begins by explaining the theoretical foundations that underlie the cognitive-behavioral therapy approach. These include the use of cognitive therapy principles that help to change the distorted thoughts and feelings of the child, combined with the behavioral interventions of exposure and response prevention (E/RP).
       The authors next describe the therapy process variables that need to be considered in order to make this treatment model successful. These variables consist of: (1) separating or “externalizing” OCD from the child and family and making it the “enemy”; (2 gradual exposure to the feared stimuli. Children are not able to handle anxiety as well as adults, therefore the child should not be forced to expose themselves to an anxiety producing stimuli that they are not ready to handle; (3) child control versus therapist control of the treatment process. Child is placed in a position where they are responsible for “bossing the OCD” back and selecting the E/RP target behaviors, while therapist is in the role of “coach”; (4) the child’s developmental level is considered in terms of cognitive functioning, social maturity, and capacity for sustained attention. All interventions need to be modified to fit the developmental abilities of the child; (5) the extent of family involvement in the treatment process. Family involvement is based on: (1) the extent to which family members are tangled up in the OCD; and (2) the extent to which family problems interfere with treatment. Family members are expected to participate to some extent and they are always given extensive educational information on OCD and the treatment process; and (6) therapist style needs to be more directive and active than in traditional “play therapy” approaches.
       In the following section the authors outline the four steps of the CBT treatment. The steps are: (1) psychoeducation; (2) cognitive training; (3) mapping OCD symptoms; and (4) graded exposure and response prevention. Logistical concerns regarding treatment, such as number, length, and location of sessions, are also explored.
       At the end of the chapter the authors discuss the process of tracking client progress and evaluating treatment success. They recommend that the child’s symptoms be tracked and graphed on a weekly basis, so that reductions can be readily observed by the child, parents, and therapist. It is also suggested that the child’s hierarchy of feared stimuli, along with their weekly SUDS ratings be graphically displayed for the child and family to see. Once again, visual monitoring can be very encouraging to the child and the family, especially during times when the therapeutic work is more challenging. The authors conclude the chapter by outlining the remainder of their book, which provides detailed guidelines on how to implement their CBT treatment.

Shafran, R. (1998). Childhood obsessive-compulsive disorder. In P. Graham (Ed.), Cognitive-Behavior Therapy for Children and Families (45-67). New York, NY: Cambridge.

This chapter presents the cognitive-behavioral perspective of child and adolescent OCD. The author begins with a brief but richly inclusive overview of findings from all major descriptive, epidemiological, familial and CBT studies of OCD in children, noting where differences exit between childhood and adult OCD. Included in this introduction is a thoughtful examination of the discrepancies found between clinical and community sample estimates. Next, a clear analysis of OCD from both the behavioral and the cognitive perspective is presented and integrated into a strong rationale for the use of a cognitive behavioral model in the treatment of OCD. This perspective places OCD within a learning model, with normal/abnormal though intrusions regarded as functioning along a continuum. The author notes that the literature on treatment of OCD in child populations: (1) does not clearly differentiate behavior therapy (BT) from CBT, and; (2) emphasizes the behavioral rather than the cognitive component of CBT. Following this section, the author provides a state of the art description of the assessment process, assessment techniques, and assessment instruments most useful in the assessment of childhood OCD. The author notes that accurate assessment is critical to effective CBT treatment of OCD. CBT treatment techniques are carefully and concisely outlined and two case illustrations are provided (one of which emphasizes the cognitive component of CBT). The author describes the benefits of multicomponent therapy which incorporates a family and possibly a school component as well as drug treatment. Finally, noting that "there have been no group comparisons, systematically controlled treatment trials, or replications studies," the author reviews the existing evidence for the effectiveness of CBT for childhood OCD. Treatment literature of childhood OCD and reported treatment outcomes are presented. The author concludes that there is abundant clinical evidence for the effectiveness of CBT in the treatment of childhood OCD but notes the urgent need for empirical research studies which confirm her conclusions.

Foa, E. B., Franklin, M. E., & Kozak, M. J. (1998). Psychosocial treatments for obsessive-compulsive disorder: Literature review. In R. P. Swinson; M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive-compulsive disorder: Theory, research, and treatment (pp. 258-276.). New York, NY: Guilford.

       As the title indicates, this article provides a review of the literature on the psychosocial treatments for obsessive-compulsive disorder. The authors begin by discussing the history of treatment interventions used to treat OCD, and observe that until the mid-1960’s, OCD was considered a refractory psychiatric condition that responded poorly to both psychodynamic therapy and then-available medications. In the decades that followed, research began on the use of behavioral techniques, derived from learning theory, to treat OCD. A treatment that proved to be effective with adult populations combined exposure to the feared stimuli, with ritual (or response) prevention (EX/RP). In Foa and Kozak’s (1996) review of 12 outcome studies utilizing EX/RP, 83% of patients were classified as immediate responders (responders are patients who show a 30% or greater reduction in OCD symptoms). A review of 16 long-term outcome studies indicated that 76% of patients were responders at follow-up (mean follow-up interval of 29 months).
       The authors reviewed the literature on the different treatment variables associated with EX/RP. In studies that examined the effects of Exposure versus Ritual Prevention versus EX/RP, the results showed that the combined treatment of EX/RP was superior to Exposure or Ritual Prevention used independently. Other studies found that prolonged continuous exposure to the feared stimuli versus short interrupted exposure yielded better outcomes. The use of imaginal exposure in addition to in vivo exposure appears to enhance treatment gains for OCD patients, especially for individuals who have obsessional fears that focus on disastrous consequences. The authors only reviewed two studies that looked and family involvement in EX/RP treatment and both studies focused on adult OCD patients. The results of these two studies were mixed and the authors site methodological problems in each.
       The research on EX/RP compared to various cognitive therapies show mixed results as well.    The authors state that the question of whether cognitive therapy improves the efficacy of EX/RP is “moot”, since dysfunctional thinking and mistaken beliefs are often a component of the EX/RP treatment process. In studies examining the relative and combined efficacy of EX/RP and pharmacotherapy, the authors conclude that “EX/RP is the best available treatment for patients who are willing or able to complete it”. They note that the superiority of pharmacotherapy plus EX/RP is unclear at this time.
       The final section of this article looks at the research on predictors of treatment outcome such as: (1) pretreatment depression; (2) pretreatment OCD severity; (3) the presence of personality disorders; (4) patient’s expectancy of outcome; and (5) patient’s motivation and compliance with treatment. The authors conclude by stating that EX/RP is the current treatment of choice for OCD, but caution that many patients refuse to participate in the treatment because it sounds threatening, and that access to qualified clinicians trained in EX/RP is often limited. They propose that further research be conducted on the efficacy of EX/RP.

       Rapoport, J. L., & Inoff-Germain, G. (1997). Medical and surgical treatment of obsessive-compulsive disorder. Neurologic Clinics, 15(2), pp. 421-428.

       This article contains a review of the literature regarding the current medical and surgical treatments of OCD. The authors begin with a brief description of OCD symptomatology and observe that the disorder is often accompanied by other psychiatric disorders (e.g.: Tourette’s Syndrome), which can make diagnosis complex.
       The drug treatments first examined by the authors fall under the general category of serotonin reuptake inhibitors (SRIs) and selective serotonin reuptake inhibitors (SSRIs). The SRI that has been most fully researched is Clomipramine (CMI), which has been found to reduce OCD symptoms by 40% in adult experimental populations, whereas the reduction in adult control populations is only 4%. The SSRIs studied include Fluoxetine, Sertraline, Paroxetine, and Fluvoxamine, and their use yields a 60% to 75% improvement in adult patients. The authors state that the research suggests that all of the above-mentioned drugs can also be used with children and adolescents, however, more research is indicated. Information is also provided on two augmenting drugs (Clonazepam and Haloperidol), which can be used in conjunction with the SRIs and SSRIs to increase their effectiveness. In addition, other psychopharmacological agents are described that can be utilized when the patient has comorbid disorders such as depression, ADHD, and Tourette’s Syndrome.
       The article next describes the literature regarding neurosurgical treatment, which is only utilized in cases where the patient’s condition is chronic and deteriorating, and other treatment options have failed. It is estimated that 10% of OCD patients fall into the above category and neurosurgical techniques have been shown to produce long-term improvement in 30% to 45% of OCD patients. The authors note, however, that neurosurgical techniques are still considered experimental at this time and more rigorous studies are indicated.
       The authors conclude by saying that medical and surgical treatments for OCD have greatly improved over the past decades, but despite these advances there is still considerable variability in patient response to these treatments.

Hohagen, F., Winkelmann, G., Rasche-Rauchle, H., Hand, I., Konig, A., Munchau, N., Hiss, H., Geiger-Kabisch, C. Kappler, C., Schramm, P., Rey, E., Aldenhoff, J., & Berger, M. (1998). Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo. British Journal of Psychiatry, 173 (Suppl.35), 71-78.

       This study compared the efficacy of a combined treatment of Multi-Modal Behavior Therapy (BT) and Fluvoxamine with BT and a placebo medication, on severely ill adult in-patients with obsessive-compulsive disorder. The researchers used a randomized, double-blind study design and participants consisted of 60 adult in-patients who had been diagnosed with OCD using the Structured Clinical Interview for DSM-III-R (SCID; Spitzer et al., 1984). Patients’ symptoms were measured using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al, 1989), the Hamilton Depression Scale (HAM-D; Hamilton, 1960); the Clinical Anxiety Scale (CAS; Snaith et al., 1982); the Global Assessment Scale (GAS; Spitzer et al., 1984); the Clinical Global Improvement Scale (CGIS: National Institute of mental health, 1976); and the Symptom Check List (SCL-90-R; Derogatis et al., 1976; Franke, 1995).
       The behavioral treatment consisted of three weeks of behavioral analysis, followed by the implementation of graduated exposure and response prevention during weekly treatment sessions that lasted a minimum of three hours. The treatment lasted for approximately ten weeks.
       The results of this study showed that after treatment each group had a significant reduction in OCD symptoms. There were no group differences in the reduction of compulsions, however, the BT plus Fluvoxamine group had significantly fewer obsessions than the BT plus placebo group. The authors also found that severely depressed patients who participated in the BT plus placebo group, had significantly worse treatment outcomes as measured by the Y-BOCS.
       The authors conclude that the combination of BT and Fluvoxamine may be beneficial when obsessions dominate the clinical presentation of OCD and secondary depression is diagnosed.

II. DEVELOPMENTAL PERSPECTIVE

       When providing treatment to a child or adolescent for Obsessive-Compulsive Disorder it is critical that developmental issues be taken into account. Developmental considerations which may impact treatment include: language-competence, level of therapeutic participation, temperament, developmental maturity, the unknown, but potentially adverse effects of psychopharmacological treatment with young children, and dynamic interactional relationship between the child, the child's environmental context, and OCD symptomatology.
       CBT and E/RP both incorporate educational components, which depend upon the child’s ability to understand the concepts and principals of the therapy program (Wiesz,1998). Additionally, CBT approaches utilize and rely greatly upon self-directed language (i.e. “self-talk”). Thus, language-competence is a critical issue to consider with respect to children who, due to developmental level, developmental delay, or communication disorders are limited in language development. While CBT does allow for adjusting the therapeutic conversation to the child’s developmental level, it is unclear how children with limited language abilities may be able to benefit form CBT.
       A second developmental consideration examines the level of therapeutic participation which is required of the child for successful treatment outcomes (Shirk & Russell, 1998). In order for children to benefit from CBT, they need to be active collaborators in their therapy. However, children do not typically self refer themselves into treatment. Rather, they are frequently brought to treatment by parents or other adults and may enter treatment with some reluctance due to lack of understanding or negative ideas about therapy). This resistance may impact their level of therapeutic participation. Thus, it is critical that treatment approaches develop a “shared definition” of the problem (OCD) and the solutions (the treatment approach), in order enlist the child’s collaboration (Shirk & Russell, 1998). Fortunately this developmental concern is directly addressed through the educational and reinforcement components of CBT.
       Other developmental factors which may impact the child’s level of participation with CBT treatment in particular are temperament and developmental maturity. Given that E/RP requires the child tolerate intense discomfort, anxiety, and fear, children who are developmentally immature or temperamentally sensitive may not respond positively to this approach (King, Leonard, & March, 1998). In these cases, King, Leonard, & March, (1998) suggest that relaxation therapy may help children complete the E/RP tasks. Thus CBT approaches are able to respond to these factors. Temperament and developmental maturity are also critical in achieving treatment compliance with pharmacotherapy, as many clients: (1) do not experience treatment effects until, 6 to 10 weeks of treatment; (2) may experience exacerbation of OCD symptoms during the first 10 days of treatment; and; (3) may experience side effects such as nausea, headache, gastrointestinal complaints, agitation, etc. Recommendations for this situation include beginning with low dosages which increase slowly, explaining to children that these symptoms will subside, and encouraging children to continue the medication.
       Given that children and adolescents are still developing, many clinical and parents may be concerned about decreasing any potential risks associated with use of pharmacotherapy. The expert consensus guidelines provide important recommendations which may help address this unknown risk. These guidelines indicate that with children and adolescents CBT (E/RP with cognitive therapy) is the first line of treatment. With treatment resistant children and adolescents, the guideline also suggest increasing the intensity of CBT (e.g. from weekly to daily) as well as changing CBT approaches. Finally, with children exhibiting treatment resistance to CBT and manifesting severe OCD the guidelines recommend the addition of pharmacotherapy. Clearly, then the guidelines proved an effective way to balance the unknown risk of potentially adverse effects of psychopharmacological treatment against the child’s need for effective treatment of OCD.
       Finally, from a developmental perspective, treatment needs to attend to the interaction process between the child, environmental context, and the disorder. Peer, school, and family interactions both impact and are impacted by the child’s disorder. According to King, Leonard, and March, (1998), "OCD frequently occurs in the context of other psychopathology and adaptive difficulties...[therefore] family psychotherapeutic...and educational interventions often are necessary." For example, parents, teachers, and family members frequently do become entangled in the compulsive behaviors manifested by children. Clearly, disentanglement needs to occur as part of an effective treatment plan. As discussed above, CBT approaches do consider the relationship between thoughts, behavior, feelings and the child’s functioning in the larger social context. Thus, CBT approaches do address this developmental considerations. Psychopharmotherapy, on the other hand, does not explicitly seek to intervene upon the child's environmental context. Therefore, when psychopharmotherapy is the sole treatment approach utilized, it is highly unlikely that treatment will address these developmental considerations.

III. OPTIMAL TREATMENT

        When addressing the question of what is the optimal approach for treating childhood obsessive-compulsive disorder, one must consider the child or adolescent as a whole and complex individual who is functioning and developing within the context of many different environments. Therefore, the treatment strategy needs to be multifaceted and have the ability to interface with the various systems in which the child functions and meet the individual needs of the child. The literature suggests that the first-line treatment for childhood OCD is the implementation of Cognitive-Behavioral Therapy (CBT). The CBT approach incorporates elements of behavior therapy, which involves the specific use of Exposure and Response Prevention (E/RP), as well as Cognitive Therapy techniques which address the child’s distorted cognitions and feelings of over-responsibility. E/RP involves exposing the child to feared situations or cues, combined with blocking their ritualized responses. The manualized CBT treatment outlined by March and Mulle (1998) provides detailed instructions on how to implement CBT in a manner that is sensitive to the developmental and environmental needs of the child.
       When OCD symptoms are more severe, pharmacotherapy may be an option for some children and adolescents. Ideally, the implementation of pharmacotherapy is combined with a CBT treatment program. The medications most commonly used to treat OCD are the serotonin reuptake inhibitors (SRIs) such as clomipramine, and the selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine, fluvoxamine, paroxetine, and sertaline).   Clomipramine is currently the only OCD medication approved for children and adolescents age 10 and older by the FDA. Although all of the SSRIs may be effective treatments for the reduction of OCD symptoms, further research studies are necessary before any strong conclusions can be drawn.
        It is important that parents and family members be included in the treatment process whenever possible, since more often than not, parents and family members become inadvertently involved in the compulsive rituals of the child (Albano, Knox, & Barlow, 1995; March & Mulle, 1998). March and Mulle (1998) state that the developmental level of the child should also be considered and may dictate the amount of involvement a parent will have in the therapeutic process. Young children depend more on their parents to help them with their daily needs and may require more active participation by parents in carrying out E/RP homework assignments. Adolescents, on the other hand, may be more self-directed in treatment.
       Lastly, as part of any treatment program it is important that OCD symptoms and treatment progress be tracked on a regular basis. Since OCD is a chronic, and often vacillating disorder, accurate documentation of current symptoms and visual displays of these changes can offer hope and encouragement to both the child and the family.

IV. CONCLUSION
Based on the treatment literature of childhood OCD, it is clear that clinical evidence strongly supports the treatment recommendations of the Expert Consensus Guidelines (March, Frances, Carpenter, & Kahn, 1997). These guidelines clearly identify CBT with family involvement as the first line of treatment. In the writers’ opinion, this approach is best suited to the inclusion of the key developmental considerations which must be addressed in the treatment with children and adolescents with OCD. Combined CBT and drug therapy is considered only as a second line of defense, and this too is in line with need to take into account the risk posed by subjecting young children’s developing systems to prolonged drug treatments. While it is clear that these treatments are at least partially effective, the literature on OCD life outcomes does suggest that for most children with OCD, treatment will improve but not completely remove OCD symptomotology. Notably, CBT is most effective in long-term maintenance of treatment gains and prevention of treatment relapse. Thus, it can not be over-emphasized that children and adolescents with OCD are best served when they are provided with CBT as at least one component of their treatment for OCD.

V. WWW SITES

1). http://www.ocfoundation.org/ocf1030a.htm

This web site is sponsored by the Obsessive-Compulsive Foundation and it focuses exclusively on the treatment of OCD. The site is organized into four primary categories: education, psychotherapy, medication, and treatment maintenance. The education category provides practical information on topics such as: (1) What can I do to help my disorder?; (2) How often should I talk to my clinician?; (3) What should I do if I feel like quitting?; and (4) What can family and friends do to help? The psychotherapy section provides a detailed description of Cognitive Behavioral Therapy (CBT), and how it is used to treat OCD. Also included is a list of commonly asked questions regarding this treatment approach. The next category covered is the use of medication to treat OCD. This section not only outlines the various medications available to OCD patients, it also addresses issues such as side-effects, how to negotiate managed care systems, and what to do if you cannot afford the medications. The final category discusses treatment maintenance and gives recommendations for follow-up treatment and support group referrals.
It appears that this web site would be very useful and informative for an individual diagnosed with OCD and for friends and family members of OCD patients. The site provides practical suggestions on how to facilitate the treatment process and gives clear information about what to expect along the way.

2). http://www.psychguides.com/eks_ocgl.htm

This site provides a superbly organized set of "Expert Consensus Guidelines" for the treatment of OCD as well as an equally informative and well-organized "Patient-Family Handout". The ten guidelines are: (1) Selecting the initial treatment strategy; (2) Selecting specific Cognitive-Behavioral Therapy techniques; (3) Selecting a medication strategy; (4) When there is still need for improvement; (5) Strategies for the refractory patient; (6) Treatment strategies for the maintenance stage; (7) Minimizing medication side-effects; (8) Treatment of OCD when complicated by comorbid psychiatric illness; (9) Treatment of OCD when complicated by pregnancy or a comorbid medical illness; and (10) Pharmacotherapy for OCD “spectrum” conditions. . Additionally, the “Guide for Patients and Families” present equally clear and comprehensive informaion answering questions such as, What is OCD? How is OCD treated? What can families and friends do to help? What is CBT? How can I find a behavior therapist in my area? What medication are used to threat OCD? What the side effects of these medicaitons?
Each of the guideline sections contain beautifully laid-out charts that compare and contrast the various options available to the OCD patient. The charts are easy to understand and allow the reader to see all of the information in a single display. Also included under each of the guideline sections, are observations and special considerations written by the “experts” concerning the specific topic. In this writer’s opinion, this was the most comprehensive and visually pleasing of all the web sites visited. It can be utilized by professionals and lay persons alike and provides excellent information regarding the treatment of OCD. This site is ideal for anyone seeking state of the art treatment information in a condensed, easy to understand, yet complete format. If one could select only one OCD treatment site, this would be the choice to make.

3). http://www.duke.edu/~vunico/pcaad/cbtocd.html

       This web site describes in detail the use of Cognitive-Behavioral Therapy (CBT) with children and adolescents diagnosed with OCD. The site appears to be geared more toward the professional community and individuals wanting more theoretical and applied knowledge of CBT.
       The author begins with a brief description of the proven efficacy of CBT with adult OCD patients, and then gives a summary of the theoretical application of CBT to OCD.   This is followed by a comprehensive description of how CBT is implemented with children and adolescents. In the implementation section the author provides: (1) an overview of CBT; (2) psychoeducational strategies that can be employed by patients and their families; (3) specifics on cognitive training; (4) the process of mapping OCD symptoms; (5) implementation of exposure and response prevention; (6) relapse prevention strategies; and (7) how to involve parents in the treatment process.
       At the end of the web site the author provides numerous resources for patients, family members, and professionals facing the challenge of OCD. These resources include organizations (includes phone numbers), books, annotated references, and two pages of academic references. This web site is a great find for its resource section alone, however, the detailed sections on theory and practice are also of importance for anyone utilizing or participating in CBT to treat OCD.

4. http://www.mentalhealth.com/mag1/p5h-ocd2.html

This site presents Part I and Part II of the Harvard Mental Health Letter for Nov. and Dec. 1995, which focuses on OCD. Part II focuses on behavioral, drug, and surgical treatment of OCD. A clear explanation of Exposure Response Prevention E/RP treatment is presented, along with an explanation of how this treatment can be modified for each of the compulsion categories. Efficacy rates and alternative treatment formats such as group and self-help approaches are briefly discussed. Next, effectiveness and type of drug treatments available are concisely explained. Finally, the author present brain surgery as a last resort and discusses potential side effects. The information presented in this web site is clear, concise, and written in simplified clinical language. This site would be most useful to someone seeking a brief overview of treatment options for OCD.

5. http://www.fairlite.com/ocd/medications/medcompare.shtml

This is a clearly forrmatted summary and comparison of medications utilized in treatmetn of OCD and comorbid disorders. Each drug is listed by brand name, generic name, and class. Treatment use, eliminaiton half-life, common side-effects, potential drug interactions, addictive potential, and withdrawal symptoms are listed for each drug. This site is most useful an immediate and comprehenisve source of infomation regarding the multiitude of drugs being prescribed to people with OCD. Given the lack of easy to understand and easily accessible information about psychtropic drugs, this site is an extremely useful reference piece.

6. http://members. aol. com/charlene/treatment.html

This site focuses specifically on presenting information about OCD treatment from the perspective of a non-medical profession who has OCD. The author summarizes information she Haas gathered from her own readings about OCD. In extremely clear language, she summarizes all of the basic information available regarding medication and behavior therapy. She also provides insight regarding her own experience in treatment. A unique feature of this site is the information provided regarding Support Groups for OCD. The writer notes that support groups help people with OCD realize they are not the only one with this set of symptoms. A list of OCD support groups is provided. Finally a section on the role of family support in treatment of OCD is presented. Family members seeking helpful hints regarding how best to support their loved one with OCD will appreciate the helpful hints provided. This site is highly recommended to those seeking to learn about treatment from the perspective of one who has “gone through it.”

VI. RESIDUAL COMMENTS

OCD, once considered to be a rare disorder is now recognized to occur in about 2-4% of the population. Typically OCD has its onset in adolescence, although it can appear as early as age three. Unfortunately the literature documents the severe underdiagnosis of child and adolescent OCD. In fact, according to Long (1995), one study has found the average time delay between onset and correct diagnosis to be 17 years. Clearly, this delay in accurate diagnosis has a tremendous cost in terms of human suffering. Additionally, in the case of children, untreated OCD can have life-long deleterious effects if it is allowed to interfere with the successful completion of critical developmental psychosocial tasks. Thus, early identification and treatment of children with OCD can have a tremendous impact on the developmental pathways which may ultimately determine the life outcomes of children with OCD.
Given the remarkable improvements in both assessment models and treatment approaches which have been developed and refined over the past 10-15 years, there is much hope for positive life outcomes in children and adolescents with OCD. Of particular import is the integration of a developmental approach into the treatment of childhood OCD, as has been seen in March & Mulle’s (1998) manualized treatment for OCD. Despite these hopeful gains in the assessment and treatment of OCD, many questions still remain: What is the etiological origin of OCD? How do the SSRI’s work? What long-term effects does pharmacotherpy have on the developing child or adolescent? What treatment will ultimately be empirically identified as most efficacious in delivering the “curative effect” implied by the word treatment? As future research seeks to investigate these questions, it will be important to continue employing a developmental model which integrates the developmental characteristics of children and their environmental context into the search for greater understanding of childhood OCD.

References

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       Bolton, D. (1998) Obsessive-compulsive Disorder. In T. Ollendick (Ed.), Comprehensive Clinical Psychology, Volume 5, Children and Adolescents: Clinical Formulation and Treatment (pp. 367-391). New York: Elsevier Science Ltd.
       Foa, E. B., Franklin, M. E., & Kozak, M. J. (1998). Psychosocial treatments for obsessive-compulsive disorder: Literature review. In R. P. Swinson; M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive-compulsive disorder: Theory, research, and treatment (pp. 258-276.). New York, NY: Guilford.
       Francis, g., & Gragg, R. A. (1996). Childhood obsessive compulsive disorder. Thousand Oaks, CA: Sage Publications.
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