Teens and OCD

At least 1 in 200 kids and adolescents in the United States have Obsessive Compulsive Disorder (OCD). Understanding the special impact that the disorder has on their lives is important in helping them get the right treatment. Some common issues with OCD in kids and adolescents are as follows:

1. Anger Management Problems: This is because the moms and dads have become unwilling (or are unable!) to comply with the youngster's OCD-related demands. Even when moms and dads set reasonable limits, children and adolescents with OCD can become anxious and angry.

2. Disrupted Routines: OCD can make daily life very difficult and stressful for children and adolescents. In the morning, they feel they must do their rituals right, or the rest of the day will not go well. In the evenings, they must finish all of their compulsive rituals before they go to bed. Some children and adolescents even stay up late because of their OCD, and are often exhausted the following day.

3. Other Mental Health Problems: Children and adolescents with OCD are more likely to have additional mental health problems than those who do not have the disorder. Sometimes these other disorders can be treated with the same medicine prescribed to treat the OCD. Depression, anxiety disorders and trichotillomania (compulsive hair or skin picking) may improve when a youngster takes anti-OCD medicine. On the other hand, Attention-Deficit Hyperactivity Disorder (ADHD), tic disorders, and disruptive behavior disorders usually require additional treatments, including medicines that are not specific to OCD.

4. Physical Complaints: Stress, poor nutrition, and/or the loss of sleep can make kids physically ill.

5. Problems at School: OCD can affect homework, attention in class, and school attendance. If this happens, you need to be an advocate for your youngster. It is your right under the Disabilities Education Act (IDEA) to ask for changes from the school that will help your youngster succeed.

6. Problems with Self-Esteem: Children and adolescents worry that they are "crazy" because their thinking is different than their friends and family. Their self-esteem can be negatively affected because the OCD has led to embarrassment or has made them feel "bizarre" or "out of control."

7. Social Relationships: The stress of hiding their rituals from peers, times spent with obsessions and compulsions, and how their friends react to their OCD-related behaviors can all affect friendships.

Experts agree that cognitive behavior therapy (CBT) is the treatment of choice for children with OCD. Working with a trained CBT therapist, kids and adolescents with OCD learn that they are in charge, not OCD.

Using a CBT strategy called exposure and response prevention (ERP), youth can learn to do the opposite of what OCD tells them to do, by facing their fears gradually in small steps (exposure), without giving in to the rituals (response prevention). ERP helps them find out that their fears don't come true and that they can get used to the scary feeling, just like they might get used to cold water in the swimming pool.

Here is an example:

Imagine a teen that repeatedly touches things in his room to prevent bad luck. Using ERP, the teen would learn to leave his room without touching anything. He might feel very scared at first, but after some time, the anxiety goes away as he gets used to it. He also finds out that nothing bad happens.

At first, ERP may sound scary to many kids and teens. They may not be ready to try it. It is important to find a CBT therapist who is experienced in working with kids with OCD. An experienced therapist will be able to get your youngster ready for ERP by making it kid-friendly.

When youth understand how the therapy works, they may be more willing to deal with the initial anxiety experienced during ERP because they know the anxiety will increase and then go down over time. Moms and dads need to be involved in their youngster's treatment as well, under the therapist's guidance.

Medicines should only be considered when there are moderate to severe OCD symptoms. Both cognitive behavioral therapy (CBT) and medicine effectively treat OCD in kids and adolescents. Their use is supported by the treatment guidelines of the American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP).

Antidepressants are usually the first kind of medicine that a doctor will try. Your doctor might refer to these medicines as SSRI's, which stands for "Selective Serotonin-Reuptake Inhibitors", or TCA's, which stands for "Tricyclics." Here are some names of each of these kinds of medicines:

SSRI's-

• citalopram (Celexa®)

• escitalopram (Lexapro®)

• fluoxetine (Prozac®)

• fluvoxamine (Luvox®)

• paroxetine (Paxil®)

• sertaline (Zoloft®)

TCA's-

• clomipramine (Anafranil®)

OCD medicines control and decrease symptoms, but do not "cure" the disorder. OCD is usually well controlled when the right treatment is in place, but symptoms can often return when the youngster stops taking the medicine.

All OCD medicines work slowly. It is important to not give up on a medicine until it has been taken at the right dose for 10 to 12 weeks. Studies have also shown that improvement of childhood OCD can continue for at least a year after starting medicine.

Only four OCD medicines have been approved by the FDA for use in kids:

• clomipramine (Anafranil®)
• fluoxetine (Prozac®)
• fluvoxamine (Luvox®)
• sertaline (Zoloft®)

But, doctors can prescribe any OCD medicines to kids if they feel it is needed.

The best dose of OCD medicine should be determined on an individual basis. Kids should start at a lower dose than adolescents, but OCD symptoms often need to be treated with higher, adult-sized doses. If a youngster has difficulty swallowing pills, a liquid or other version may be available. The following dose ranges may be necessary:

• fluvoxamine (Luvox®): 50-300 mg/day

• sertaline (Zoloft®): 50-200 mg/day

• clomipramine (Anafranil®): 50-200 mg/day

• citalopram (Celexa®): 10-60 mg/day

• paroxetine (Paxil®): 10-60 mg/day

• fluoxetine (Prozac®): 10-80 mg/day

• escitalopram (Lexapro®): 10-20 mg/day

No two kids respond to OCD medicines in the same way. In general, clomipramine (Anafranil®) is usually not given first because of its side effects.

Factors that may guide the medicine choice can include:

• a good response to a certain drug by other family members

• cost or availability

• potential for side effects

• presence of other disorders

In the largest youngster OCD treatment study to date (POTS)1, remission (the absence of any major symptoms) occurred in about 1 in 5 kids on medicine and in more than half of those with medicine and CBT. In addition, many more kids had improvement (but not full remission). Some kids will have no response at all to some medicines, but it does not mean that other medicines will not help.

Every kind of drug has potential side effects. These side effects must always be weighed against the benefit. Some common side effects of OCD medicines include:

• a heightened sense of energy

• inability to sit still

• nausea

• sleepiness or insomnia

In general, the other drugs are safer than clomipramine (Anafranil®) which has its own side effects, including:

• concentration problems

• drowsiness

• dry mouth

• problems with urination

• racing heart

• weight gain

For all antidepressants in kids and adolescents, the FDA has issued "black box warnings" about suicidal thoughts and urges. The highest risk period for this is when starting or increasing the dose of the medicine. However, a recent study found no increase in suicidal thoughts in groups of kids with OCD who were studied.

These drugs appear very safe with long-term use and side effects reverse when they are stopped. There is no current evidence that they do permanent damage to the body.

It is important to know that if the first medicine does not improve OCD, another one should be tried. Trying several OCD medicines may be needed. Many people have better results if CBT is added to drug treatment. If the combination of one drug and CBT don't work, adding a second or third medicine can also be tried.

Many doctors suggest that OCD treatment should continue for at least one year, even after the symptoms have stopped. Unfortunately, OCD drugs do not "cure" the illness. When medicine is stopped, symptoms often return within a few weeks to months. If they return, most patients will respond well after starting to take the medicine again.

 ==> My Out-of-Control Teen: Help for Parents

Children Who Abuse Their Pets

Child and teen motivations for the abuse of pets have not been studied extensively. However, case reports and a child interview study (using the Cruelty to Animals Assessment Instrument) suggest a number of developmentally related motivations.

Why Children and Teens Abuse Pets—

• Animal phobias (that cause a preemptive attack on a feared animal).
• Attachment to an animal (e.g., the youngster kills an animal to prevent its torture by another individual).
• Curiosity or exploration (i.e., the animal is injured or killed in the process of being examined, usually by a young or developmentally delayed child).
• Forced abuse (i.e., the youngster is coerced into animal abuse by a more powerful individual).
• Identification with the youngster's abuser (e.g., a victimized youngster may try to regain a sense of power by victimizing a more vulnerable animal).
• Imitation (i.e., copying a parent's abusive "discipline" of animals).
• Mood enhancement (e.g., animal abuse is used to relieve boredom or depression).
• Peer pressure (e.g., friends may encourage animal abuse or require it as part of an initiation rite).
• Post-traumatic play (i.e., reenacting violent episodes with an animal victim).
• Rehearsal for interpersonal violence (i.e., "practicing" violence on stray animals or pets before engaging in violent acts against other people).
• Self-injury (i.e., using an animal to inflict injuries on the youngster's own body).
• Sexual gratification (i.e., bestiality).
• Vehicle for emotional abuse (e.g., injuring a sibling's pet to frighten the sibling).

Research on the abuse of pets reveals the following:

• A youngster harming - or killing - a family pet is a precursor to some very serious violent behavior. Research in psychology and criminology shows that kids and teens who commit acts of cruelty against animals don't stop there – many of them move on to their fellow humans.
• Acts of cruelty toward animals are the first signs of violent pathology that includes human victims.
• Animal abuse is not just the result of a minor personality flaw in the abuser, but a symptom of a deep mental disturbance.
• Kids who abuse animals most likely are repeating a lesson learned at home from their moms and dads or guardians. They are reacting to anger or frustration with violence.
• Kids who harm family pets are at risk for other kinds of acting-out behavior and need immediate help.
• Domestic abuse is directed toward the powerless; animal abuse and youngster abuse often goes hand and hand.
• Police records indicate that a history of cruelty to animals is one of the traits that regularly appear in its computer records of adult violent criminals. Violent and aggressive criminals are more likely to have abused animals as kids.
• The youngster's violence is directed at the only individual in the family more vulnerable than himself — an animal.
• What also goes along with torturing animals is setting fires. If you smell smoke, you'd better take it seriously.

Here are some “red-flag” behaviors that a youngster may exhibit towards a pet:

1. Chasing after an obviously scared pet
2. Intentionally feeding pets harmful substances
3. Intentionally putting an animal in danger such as throwing it out the window or kicking it onto a busy street
4. Locking pets inside enclosed spaces
5. Taking pleasure in watching a pet who is in pain
6. Tying strings or chords on pet’s neck, limbs or paws
7. Violently lashing out at a pet after being reprimanded by an adult

Once detected, it is advisable that moms and dads step-in and immediately correct the behavior before it worsens.

What Parents Can Do About the Abuse of Pets—

One of the most powerful tools we have for preventing cruelty to pets is education. It is important to plant the seeds of kindness in kids early, and to nurture their development as the youngster grows. Kids not only need to learn what they shouldn't do, but also what they can do. When kids see that their pets are happy and loving, it will make the youngster feel good, too. This in turn will help the kids care for their pets' feelings.

Kids need proper education, too. Please urge your local schools to integrate humane education into their curricula. To help you, your local shelter may have outreach programs, education materials, camps, etc.

Every youngster is unique, and grown-ups should use caution and careful thought when discussing cruelty with kids. In general, kids under the age of four simply should not be exposed to cruelty. Two-year-olds can begin to learn that their actions make others (including pets) happy and sad. With two- and three-year-olds, discuss their own experiences and how they would feel if they were treated the way they treat their pets or other pets in their immediate lives. Help them relate not only the ways they would feel hurt, but also the ways they would feel happy.

With all kids under six or so, you may wish to help guide their hands so they can learn how to pet and hold their animal companions. Kids do not have fine control over their movements and impulses—they will want to treat their pets with love, but will need a little help from you to do it correctly.

Kids who are between about four and six often begin to understand basic moral concepts, such as fairness. These kids can learn to be kind to pets because the pets "deserve" it. Kids may discuss injuries they have had themselves, but do not introduce discussions about other types of injuries. Try to limit discussions of animal cruelty to the simple fact that pets can be hurt; do not describe how they can be hurt (e.g., starvation, physical abuse, etc.).

With most kids who are six to ten years old, you can begin to discuss why someone might be mean to an animal (as long as you make sure the youngster always keeps in mind that it is wrong to hurt pets). In addition, do not let discussions of animal cruelty satisfy the morbid curiosity some kids of this age may have. Kids of this age often form some of their earliest memories and impressions about the state of the world beyond their families. It is very important that grown-ups filter what these kids perceive! Even if kids witness violence as a "bad example" or as a way NOT to act, they are still witnessing violence, and can be strongly affected by it.

Many kids between 10 and 14 are exploring their self-image and reflecting upon their relationships with others. Studies indicate that kids of this age are still strongly affected by violence, so discussions about animal cruelty should still be kept free of details about the violence. Nonetheless, the issue can be raised directly—if delicately—with most of these kids. Grown-ups should make it clear that they do not condone violence in their own thoughts and behavior. Kids of this age are finely attuned to the words and actions of adults, and still rely on them as role models.

Moms and dads, educators, and trusted adults can also discuss with 10- to 14-year-olds how they would act if their peers or friends treated pets cruelly. By couching the advice in terms of what you would do if you were in a given situation, you can help kids overcome peer pressure and follow what they know is right. These kids may encounter others abusing pets—knowing that they are in the right and will be supported for standing up to it is very important at this age of strong peer pressure.

Again, with all kids – even older teens – keep in mind the importance of modeling appropriate behaviors. Our kids do emulate us, even if they wouldn't admit it. If we treat pets cruelly or as unfeeling machines, our kids will probably think that this is right or, at least, normal. The more a youngster identifies with an adult, the greater an impact that person will have on the youngster-in both good ways and bad ways.

Kids who know of animal cruelty should tell a grown-up about it. Make sure kids know who they can trust—such as moms and dads, educators, police, etc.—and nurture their trust so they can tell you.

It's vital that children who hurt pets receive intervention — including counseling and a ban on contact with animals — to prevent their violence from continuing. It's also crucial that animal guardians protect their dogs and cats from abuse and other dangers by keeping them indoors and never leaving them outdoors unattended.

Although vandalism may represent costly and psychologically significant destructiveness, smashed windshields and graffitied walls do not feel pain or cry out when they are damaged. Pets, however, do express their distress when they have been abused, and their distress calls out for attention. This article has provided an overview of the under-reported and under-studied phenomenon of pet abuse in childhood and adolescence. Addressing cruelty to animals as a significant form of aggressive and antisocial behavior may add one more piece to the puzzle of understanding and preventing youth violence.

==> Help for Abusive Children and Teens