Abstract
Introduction: Obsessive-compulsive disorder with onset in childhood or ado-lescence causes considerable distress and functional impairment. While thereis a growing body of research focusing pediatric OCD, the presentation of thedisorder in school settings has not been subject of systematic research so far.Since children and adolescents spend one-third of their time at school, the issuewarrants further research. This article aims to provide a review of the existingliterature on the topic. Method: MEDLINE, PSYNDEX and PsycINFO werescreened for data about pediatric OCD putting special emphasis on the schoolcontext. Results: Results from 9 publications suggest that many OCD-symptomsoccur in school settings with evidence for a subgroup of typical compulsionsassociated with learning activities. Obviously, OCD often leads to substantialimpairment of academic and psychosocial functioning. Discussion: An increa-sing awareness of OCD among teachers, school psychologists and school socialworkers can facilitate assessment and treatment of children with the disorder.Given the many kinds of impairments evoked by OCD, future studies shouldinvestigate typical school-related OCD-symptoms and their impact in the aca-demic and social context. The results could then serve as a basis for the deve-lopment of subsequent psychological and educational interventions.
Keywords: Pediatric; OCD–academic/psychosocial; Functioning–school;
Personnel-identification-interventions.
Received: August 18, 2013, Revised: December 1, 2013, Accepted: December 1, 2013.© 2013 Associazione Oasi Maria SS. - IRCCS
1 University of Hamburg: Psychology Department. E-mail: [email protected]
Correspondence to: Christian Fischer-Terworth, Medicusstr. 27 - 67665 Kaiserslautern, Germany
127
Life Span and Disability XVI, 2 (2013), 127-155
Obsessive-compulsive disorder in children and
adolescents: Impact on academic and psychosocial
functioning in the school setting
Christian Fischer-Terworth1
1. Introduction
1.1 BackgroundAccording to information from the Department of Health and Human Services
of the United States of America, every year 20% of children or adolescents
between ages of 9 and 17 experience symptoms of mental disorders leading
to functional impairment. If left undiagnosed and untreated, psychiatric disor-
ders tend to become chronic, and can lead to serious problems like school dro-
pout, unemployment, substance abuse or even suicide. Anxiety disorders like
generalized anxiety disorder, separation anxiety disorder and obsessive-com-
pulsive disorder (OCD) are the most common psychiatric disorders in chil-
dhood and adolescence (Helbing & Ficca, 2009).
According to DSM-IV-tr, OCD is a complex neuropsychiatric condition
classified as an anxiety disorder. The symptoms of OCD are time-consuming,
cause marked distress and/or interfere with daily living. They often lead to sub-
stantial impairment of occupational or academic functioning, social activities
and relationships with others (APA, 2000). Although the amount of scientific li-
terature on OCD in childhood and adolescence has been increasing in the recent
years, the impact of symptoms in the school setting has not been subject of sy-
stematic investigation so far.
Several publications, however, point to serious academic and psychosocial
impairment of children and adolescents with OCD, including distress from the
emergence of symptoms, academic difficulties and peer victimization (Adams,
Waas, March, & Smith, 1994; Helbing & Ficca, 2009; Dyches, Leininger, Heath,
& Prater, 2010). School-related stress can play a role in the onset, exacerbation
and maintenance of OCD symptoms (Honjo, Hirano, Murase, Kaneko, Su-
giyama, Ohtaka et al., 1989). As some parents become aware of their children’s
problems even years after the onset of the disorder, school personnel may repre-
sent “a first line of defense” (Adams, 2004) in identifying symptoms in students.
Educators may be able to recognize problem areas because they are familiar with
the behavior of students at a certain level of development. Teachers, school psy-
chologists and school social workers should play a crucial role in the process of
diagnosing and even treating students with OCD (Adams et al., 1994; Adams &
Burke, 1999; Adams, 2003, 2004). To be able to do so, acquiring basic kno-
wledge about the condition is paramount. As efficient treatment of OCD impro-
ves symptoms and overall quality of life, it should also affect academic
performance and psychosocial functioning in patients positively. This review ar-
ticle aims to delineate the presentation of OCD across school settings and to pro-
vide an overview on pediatric OCD with relevant information for educators.
128
Life Span and Disability Fischer-Terworth C.
This knowledge should help them to identify symptoms and to participate in in-
terventions.
1.2 Obsessive-compulsive disorder: an overview
1.2.1 SymptomsThe core symptoms of OCD (Rasmussen & Eisen, 1992; Jenike, 2004; Steketee
& Pigott, 2006) are obsessions and/or compulsions. Obsessions are recurrent
thoughts, images, fears or impulses intruding into consciousness which cause in-
tense anxiety or other distressing emotions. The obsessions are difficult or im-
possible to resist, although they are usually experienced as inappropriate by the
sufferer. Although the core features of OCD with onset in childhood and adole-
scence (March & Leonhard, 1996; Walitza, Melfsen, Jans, Zellmann, Wewetzer,
& Warnke, 2011) resemble the adult form strongly, symptom profiles in the pe-
diatric population sometimes differ in presentation (Kalra & Swedo, 2009). Com-
pulsions are excessive and/or unreasonable repetitive behaviors, rituals or mental
acts which patients have to perform to (a) neutralize obsessive thoughts, (b) to
produce relief from the anxiety or discomfort caused by obsessions, (c) to prevent
some possible catastrophic event being very unlikely to occur, (d) to prevent or
avoid a situation where obsessions might occur or (e) to seek reassurance.
The most frequent obsessions occurring in children and adolescents are related
to contamination, illness, death or harm coming to loved ones (Swedo, Rapoport,
Leonard, Lenane, & Cheslow, 1989; Swedo, Leonard, & Rapoport, 1990). In con-
trast to psychotic patients, OCD patients usually have at least some insight into
the irrationality of their obsessions. As the degree of insight is generally lower in
children (Helbing & Ficca, 2009), especially in young children ritualistic behavior
is a better indicator for OCD. Young children are often unaware of their obsessions
thus not being able to verbalize them (March, Leonard, & Swedo, 1995).
Even in the presence of insight, obsessions lead to high anxiety, disgust,
feelings of guilt or other discomforts. Although their nature is irrational or at
least exaggerated, it is often nearly impossible for the individual to exert vo-
litional control about obsessions which are often accompanied by intense fear
and doubt. Individuals try to ignore or suppress their obsessions and often neu-
tralize them with compulsive rituals (APA, 2000).
Common compulsions include washing, checking, repeating, counting, tou-
ching, hoarding, questioning, magical rituals and mental acts (Swedo et al., 1989;
Swedo et al., 1990). Some compulsive rituals correspond to preceding obsessive
thoughts which determine the ritual’s content. A patient with an obsession about
harm coming to a loved one e.g., may compulsively check the stove or door locks
to ensure his/her safety.
129
Obsessive-compulsive disorder in children and adolescents
Other rituals are not logically connected to the obsessions they should neutra-
lize, especially when the relationship between obsession and compulsion is of
a magic nature. This is, for instance, the case when a 8-year-old boy feels com-
pelled always to touch a radiator three times before going to bed “to prevent
his parents from becoming ill”. Many patients simultaneously exhibit more
than one symptom (March & Leonard, 1996), meaning they suffer from several
obsessions and/or compulsions.
Life Span and Disability Fischer-Terworth C.
Table 1 - Obsessions and compulsions (adapted from APA, 2000)
1.2.2 comorbiditiesMany children or adolescents with OCD have one or more other comorbid
psychiatric disorders (Honjo, 1989), which also can cause additional distress in
school settings (Fischer-Terworth, 2010). The most frequent comorbid conditions
in pediatric OCD are other anxiety disorders, depressive disorders and tic disorders.
School-aged children with OCD often have comorbid generalized anxiety disorder,
separation anxiety disorder or childhood-onset social phobia (Geller, Biedermann,
Jones, Shapiro, Schwartz, & Park, 1998). Other concomitant conditions are di-
sruptive behavior disorders like Attention Deficit Hyperactivity Disorder (ADHD),
eating disorders, schizotypal disorders (Wewetzer & Klampfl, 2004), substance
130
abuse (Adams, 2004), learning disorders (March et al., 1995) or autistic spectrum
disorders (Fischer-Terworth & Probst, 2009). The presence of ADHD, in addition
to OCD, is linked to further impairment in both academic performance and psy-
chosocial functioning, and requires separate treatment for both conditions (Geller,
2006). Furthermore, suicidal behaviors may be related to OCD (Adams, 2004). In
50-75% of adult patients, comorbid personality disorders ,develop in the course
of OCD, whereas obsessive-compulsive personality disorder (OCPD) is found in
16-30% of cases (Wewetzer & Klampfl, 2004). Some patients may be diagnosed
with comorbid obsessive-compulsive spectrum disorders (OCSD), being defined
as conditions exhibiting thoughts and repetitive behaviors similar to OCD (Jenike,
1990b; Hollander & Chapman, 1997). OCSD include substance abuse, trichotil-
lomania (compulsive hair pulling), body dysmorphic disorder, and impulse control
disorders like compulsive buying, gambling, stealing, internet or cellphone use.
Obsessive-compulsive disorder in children and adolescents
Table 2 - Comorbid disorders in pediatric OCD in the samples of two epidemiologic studies by Swedo et al. (1989) and Wewetzer (2001; see Wewetzer & Klampfl, 2004)
1.2.3 Epidemiology and course of pediatric OCDThe estimated prevalence of pediatric OCD varies from 0.4 to 4% (Swedo
et al. 1989; also see Wewetzer, 2004a; Geller, 2006). Around 50-70% of OCD
cases begin in childhood, although the disorder is more likely to be diagnosed
in late adolescence or in early adulthood (Rasmussen & Eisen, 1992). OCD is
equally common in males and females, whereas onset between age 6 and 15
is more common in males. Some thoughts, fears and ritualized behaviors, such
as bedtime rituals or ritualized games, have to be considered as normal in dif-
ferent stages of childhood development (Wewetzer, 2004a). Unlike these phe-
nomena, OCD-related rituals consume much more time and are associated with
anxiety or other discomfort.
131
Initially, such thoughts and behaviors may be difficult to identify for parents
and even patients because they present similarily exaggerated variants of nor-
mal behaviors (Dyches et al., 2010).
Typically, the onset of symptoms is gradual. In cases of successful treatment,
nearly 50% of patients show remissions or subclinical symptoms over the long
term. Around 25% develop an episodic course with periods of increasing and
decreasing intensity, another 25% move towards a chronic course with mode-
rate to severe symptoms (Jans & Wewetzer, 2004). Obsessions and compul-
sions tend to change in severity which means that intensity and frequency of
symptoms vary over time. A patient can feel compelled, for example, to check
a light switch 10, 30 or 60 times a day, he can perform a washing ritual 30 or
120 minutes a day, or he may experience aggressive obsessions occasionally
or permanently. Symptom profiles often change, so a child having contamina-
tion fears and a washing compulsion may later engage in e.g. compulsive coun-
ting (March & Leonhard, 1996).
1.2.4 Diagnosis and differential diagnosisPsychiatric diagnosis of OCD is based on DSM-IV-TR criteria (APA, 2000),
and includes the following components: (a) neurological assessment, (b) cli-
nical interviews with patients and parents, (c) behavioral observation, (d) the
administration of self-report questionnaires, and (e) neuropsychological tests
in some cases. The gold standard instrument for diagnosing OCD is the Chil-
dren's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Goodman, Price,
Rasmussen, Riddle, & Rapoport, 1991), a modification of the YBOCS, a re-
liable and widely used adult measure. The CY-BOCS has been designed to as-
sess content and severity of OCD symptoms in children and adolescents aged
from 6 to 17. OCD warrants an exact differential diagnosis (Montgomery, Fi-
neberg, & Montgomery, 1992), as symptoms may mimic other disorders. Pa-
tients with obsessive compulsive personality disorder (OCPD) generally have
a personality pattern involving rigidity, perfectionism and preoccupation with
rules, order and/or cleanliness. In contrast to OCD-patients, they do not expe-
rience distressing obsessions and compulsions (Rasmussen & Eisen, 1992).
Although rituals related to autistic spectrum disorders (ASD) can resemble
the compulsions of OCD, they are mostly associated with special interests,
have the character of stereotypies or provide some structure and safety for the
individual (Fischer-Terworth & Probst, 2009). Furthermore, students with ASD
normally experience significantly more difficulties with communication and
relating to others than individuals with OCD (APA, 2000). In school, OCD-
related concentration deficits and distractability are caused by the interference
132
Life Span and Disability Fischer-Terworth C.
Obsessive-compulsive disorder in children and adolescents
of obsessions and may be confused with symptoms of ADHD. OCD in chil-
dhood may also be associated with learning disorders such as dysgraphia, dy-
slexia, deficiencies in arithmetic and expressive written language, slow
processing and inefficiency (March et al., 1995) which have to be separated
from e.g. compulsions related to writing.
1.2.5 Etiology and pathogenesisAs concordance is greater among monozygotic (80-87%) than among di-
zygotic twins (47-50%), and as there is an increased prevalence among first-
degree relatives of patients, research points to a genetic basis of OCD (Nestadt,
Grados, & Samuels, 2010). Especially in the childhood onset of OCD, the ge-
netic component seems to be crucial (Walitza et al., 2010). Cases of OCD
which are directly preceded by infections like encephalitis or head injury (Ste-
ketee & Pigott, 2006) point to a neurological origin of the disorder.
Neuroimaging studies of the 1990s have contributed much to understand
OCD’s underlying neurobiology (Saxena, Brody, Schwartz, & Baxter, 1998).
They demonstrate differences in regional brain activity, especially in loops
between the orbital-frontal cortex, the striatum and the thalamus, which also
applies to children and adolescents (Huyser, Veltman, de Haan, & de Boer,
2008). This abnormal activity can shift toward normal after either successful
treatment with medication or cognitive-behavioral therapy (Schwartz, Martin,
& Baxter, 1992). OCD patients’ response to medications acting on serotonin
also demonstrate an important role of the serotonergic neurotransmitter system
in the pathophysiology of OCD.
According to the theory of Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), OCD may be associated
with an autoimmune reaction in response to a streptococcus infection in some
children. Antibodies could then trigger an inflammatory reaction in striatal areals
which may cause OCD symptoms (Swedo et al., 1990). The PANDAS condition
has been described by some typical features like e.g. sudden onset of symptoms
following a strep infection, an episodic course, separation anxiety, fine motor
changes and joint pain (Helbing & Ficca, 2009).
In children and adolescents vulnerable to OCD, the onset or symptom exa-
cerbations can be linked to critical life events like e.g. divorce of the parents.
Honjo et al. (1989) found that incidents related to school frequently precede
OCD symptoms. Such triggers can be revealed as distress with peers and tea-
chers, changing schools or pressure to perform (Adams, 2003). Psychological
stress caused by life events goes along with an excess production of stress hor-
mones like cortisol which can precipitate rewiring of OCD-related neuronal cir-
cuitry (Moll, Hüther, & Rothenberger, 1999) in persons predisposed for OCD.
133
Life Span and Disability Fischer-Terworth C.
As OCD clearly has a neurobiological origin, it is the basis of the individual’s
vulnerability to OCD and not the parents’ misdirected education which deter-
mines the response to stressful events with obsessions and compulsions.
1.2.6 Treatment
(a) Cognitive-behavioral therapy. Effective treatment of pediatric OCD includes
cognitive-behavioral therapy (CBT; March, Franklin, & Foa, 2005) and medica-
tion with Serotonin Reuptake Inhibitors (SRIs; Gentile, 2011). CBT is based on
the behavioral method of exposure and response prevention (ERP), and further
includes components like cognitive therapy and psychoeducation (Kircanski,
Peris, & Piacentini, 2011). ERP means gradual exposure to fear-provoking situa-
tions and the prevention of compulsive rituals. Working up from less to more an-
xiety provoking symptoms, the therapist encourages the patient not to engage in
compulsive rituals for increasing periods of time, although the obsessive thought
or the compulsive urge is present. A child with a washing compulsion triggered
by fear of poisoning herself by touching garden plants, will be encouraged to touch
the contaminated object, in that case the potentially poisonous plant, and then to
refrain from washing, for example, for 15 or 30 minutes. After repeating the exer-
cise, typically the anxiety associated with the triggering stimulus lessens, as does
the urge to perform the compulsive ritual. Consequently, the period of exposure
time can be extended e.g. to 45, 60 or 120 minutes. ERP should be part of a mul-
timodal psychotherapeutic approach, and include management of emerging emo-
tions, cognitive relabeling of symptoms and/or refocusing on adaptive behaviors.
The cognitive part of CBT helps children to increase their ability to do an realistic
appraisal of the sítuation despite the fact that an obsession is present. It also makes
sense that children learn to relabel obsessions and compulsive urges as symptoms
of OCD, a disorder of brain chemistry (see Schwartz et al., 1992).
Further cognitive strategies are: identifying irrational beliefs, dysfunctional
thought patterns and minimizing thought suppression (March et al., 2005).
OCD-related cognitions to be challenged are an exaggerated sense of risk, a
feeling of excessive personal responsibility for events or persistent doubt. Te-
chniques have to be adjusted to the developmental stage, as young children
may not understand the sense of exposure or challenging distorted thoughts.
Therefore, relabeling thoughts by using age-appropriate metaphors like a littledevil ( a monster or a figure in a cartoon) in the head is telling you wrongthings like “This plant will contaminate you, cause an illness or kill you, you
have to wash your hands“) can be effective methods for younger children (also
see March & Mulle, 1998; Helbing & Ficca, 2009).
134
In the psychoeducational part of CBT, the therapist provides information to
patients and their parents, for instance, about the nature of OCD as a brain di-
sorder. Psychoeducation can also help to free parents from feelings of guilt or
shame and include explaining the rationale for a chosen treatment strategy.
(b) Medication. For most OCD patients the combination of CBT with the
use of medication is the most effective approach (Jenike, 2004). Treatment of
pediatric OCD is preferably focused on CBT and medication doses are chosen
generally lower (Wewetzer, 2004b). Children and adolescents successfully trea-
ted with CBT can stay in good health over the long term. Patients additionally
treated with medication are generally able to maintain improvement after tape-
ring medications (March, 1995). Medication with serotonin reuptake inhibitors
(SRI) has proved to be successful in children and adolescents with OCD (see
Table 3). SRIs block the reuptake pumps for serotonin thus increasing extra-
cellular serotonin levels and enhancing serotonergic neurotransmission. The
tricyclic antidepressant clomipramine, also a potent SRI, was the first medica-
tion shown to be effective in pediatric OCD, the action on serotonin being cru-
cial for clomipramine‘s antiobsessional effects (Wewetzer, 2004b). Today the
selective serotonin reuptake inhibitors (SSRIs) are often prefered. SSRIs selec-
tively act by selectively increasing serotonin levels and generally have fewer
side effects than clomipramine. SSRI’s side effects like nausea, sweating or diz-
ziness disappear after 4-7 days after starting the medication in most patients.
Obsessive-compulsive disorder in children and adolescents
Table 3 - Medication for pediatric OCD: Serotonin reuptake inhibitors (SRI) incl. dosages; possible augmenting agents in cases of insufficient SRI-response and/or comorbidities
135
Legend: TCA = Tricyclical Antidepressant; SSRI = Selective Serotonin Reuptake Inhibitor
However, recent research suggests that especially sertraline and, again, clo-
mipramine should be considered as first-choice medication for pediatric OCD
(Gentile, 2011). The fact that clomipramine additionally acts on other neuro-
transmitters like, for instance, noradrenaline, may account for a slight supe-
riority in efficiency over SSRIs in some patients. When SRIs work, they can
reduce on average 30-70% of symptoms. Increased levels of serotonin help to
reduce anxiety levels and the intrusiveness of obsessions, allowing the indivi-
dual to respond to compulsive urges in a more controlled fashion. Moreover,
the medications facilitate CBT making it easier to relabel OCD symptoms and
to engage in exposure exercises. It may take from 6-12 weeks until patients
respond to clomipramine or an SSRI. Increasing the dose may be necessary to
achieve optimal results. Any medication used to treat OCD should not be di-
scontinued abruptly, but tapered slowly. When first-line medications fail, swit-
ching from an SSRI to clomipramine is indicated. There are currently no
controlled data examining the use of medications in SRI-nonresponders (We-
wetzer, 2004b), but there are several options the clinician may consider. If SRI
monotherapy is insufficient, augmentation with atypical neuroleptics like ri-
speridone or tiapride may be effective (McDougle, 1992), the latter especially
in the presence of concomitant tic disorders. When OCD and ADHD symptoms
co-occur, combining an SSRI with methylphenidate is possible (Jenike,
1990a). In cases of severe anxiety, augmenting SSRIs with the serotonin-re-
ceptor-agonist buspirone (Wewetzer, 2004b) can more helpful than anxiolytic
agents like as clonazepam, which should only play a role in the short term ma-
nagement of anxiety or panic in severe OCD (Knölker, 1987).
2. Method
To review literature on pediatric OCD with special emphasis on the school
context, MEDLINE, PSYNDEX and PsycINFO as well as data bases for e-
books, diploma and doctoral theses and google were screened. The search
terms, ‘obsessive compulsive disorder’, ‘OCD’, ‘obsessions’, and ‘compul-sions’ were combined with ‘children/childhood’, ‘adolescents/adolescence’as well as with ‘school’, ‘academic’ and ‘psychosocial’. Information was also
searched for in textbooks on pediatric OCD. The data found was extracted
from reviews, studies and textbooks and a complete set of 9 papers on OCD
in the school setting. The papers include 6 journal papers, 1 monography, 1
diploma thesis and 1 online article. As the revealed literature has to be regarded
as preliminary, all the papers contain unsystematic literature reviews, 3 of them
136
Life Span and Disability Fischer-Terworth C.
including non-controlled studies with small sample sizes.
Sabunguoclu and Berkem (2006) interviewed n = 26 patients with pediatric
OCD about the distribution of symptoms across home and school settings using
standardized diagnostic instruments. Boekhoff (2000) conducted retrospective
interviews with n = 14 patients with onset in childhood or adolescence, Fi-
scher-Terworth (2010) administered a semi-structured, email-sent question-
naire answered by n = 17 patients, both authors using frequency analysis and
qualitative content analysis (Mayring, 2008). All the papers reviewed provide
general information about pediatric OCD, and discuss typical manifestations
of symptoms in school, the impact on academic performance and peer rela-
tions. Furthermore, they focus identification of OCD symptoms in the school
setting and discuss possible educational interventions.
3. Results: Obsessive-compulsive disorder in the school setting
According to a review of 67 articles on pediatric OCD by Geller et al. (1998),
school avoidance, school refusal and academic difficulties are common in the
population. Often children and adolescents with OCD have to repeat a year,
change schools or even drop out of school (Knölker, 1987). Many of them
have to tolerate general major psychosocial impairments (Probst, Asam, &
Otto, 1979) and show low levels of social competence (Hanna, 1995). In later
life, many patients are discontented with their job situation with unemployment
rates between 40 and 50% (Hohagen, Rasche-Räuchle, Winkelmann, König,
Münchau, Geiger-Kabisch et al., 1997). As OCD is a chronic condition, it is
associated with social isolation, the development of comorbid psychiatric di-
sorders and an increased prevalence of suicide (Jans & Wewetzer, 2004).
The impact of OCD on psychosocial functioning was studied by Piacentini,
Bergman, Keller and McCracken (2003) in n = 151 patients with pediatric OCD.
Nearly 50% had substantial OCD-related problems in the school setting, at home
and in social contexts. The two most common problem areas were concentrating
on work in class and problems with completing homework. Furthermore, the se-
verity of impairments was significantly correlated with symptom severity (Pia-
centini et al. 2003). Although children and adolescents with OCD seem to
experience the highest levels of distress and impairment at home (McGough,
Speier, & Cantwell, 1993; Valderhaug & Ivarsson, 2005; Sabunguoclu & Ber-
kem, 2006), and mild OCD may not interfere with academic or social functio-
ning, many distressing symptoms are experienced in school-related settings. Of
a total of 57 patients with pediatric OCD from three small samples (Boekhoff,
137
Obsessive-compulsive disorder in children and adolescents
2000; Fischer-Terworth, 2010; Subanguoclu & Berkem, 2011), 37 patients (65%)
reported to have at least moderate symptoms in the school context.
3.1 Manifestations of classical OCD symptoms in the school setting In literature, some descriptions of characteristic manifestations of school-
related OCD-symptoms can be found (Boekhoff, 2000; Adams, 2004; Dyches
et al., 2010; Fischer-Terworth, 2010). Compulsive washing is commonly as-
sociated with fear of contamination with dirt, germs or poisons. Also frequen-
tly, disgust associated with sticky substances or bodily secretions can trigger
washing compulsions. In school, children and adolescents may be driven to
leave the classroom to wash their hands. They may excuse themselves to go
to the lavatory or perform the compulsion during the breaks (Adams, 2004).
Furthermore, they may avoid touching e.g. doorknobs, tables or lunch trays or
refrain from sharing items used by other students (Dyches et al., 2010).
In the case of checking compulsions, patients repeatedly check door locks,
electrical appliances or water taps. They also tend to reassure themselves that
nothing terrible has happened. A student interviewed by Boekhoff (2000) had
repeatedly to check a window to make sure that no student could fall out of
the window. Another student (sample of Fischer-Terworth, 2010) felt compel-
led to phone his mother compulsively every break to reassure himself that she
was OK. When nobody answered the call, he felt the urge to rush home to
check that nothing terrible had happened.
Through compulsive questioning students may check and reassure themselves
if they have learned enough or if they have done everything the right way.
School-related obsessive fears can be associated with the constant doubt that a
school task hasn’t been accomplished perfectly. The obsessions may be followed
by repeated checking, questioning or ruminating. The obsessive fear of loss can
also trigger compulsive hoarding of personal items. In these cases, students may
make sure that personal items are secure by hoarding things that seem useless to
others (e.g. old magazines, books, notes or lists; Fischer-Terworth, 2010).
Students with ordering compulsions may arrange and rearrange e.g. books,
pencils or other items on their desk in an exact symmetrical order. Adams (2004)
states that in school they may be compelled to pronounce a word just right on
each syllable, draw lines and tables in a painstakingly exact way, carefully mea-
sure each footstep or tie shoelaces with exact equal length. Such compulsions can
be associated with feelings of incompleteness or obsessions about terrible things
that might happen (Rasmussen & Eisen, 1992). Many patients with pediatric OCD
have to carry out magical rituals like repeatedly counting up to a particular magic
number, touching certain items, repeating something else to prevent a potentially
138
Life Span and Disability Fischer-Terworth C.
threatening event or to neutralize inacceptable obsessive thoughts. Repeating com-
pulsions occurring in class can manifest themselves as the repeated sharpening of
pencils, repronouncing sentences endlessly (Adams, 2004), avoiding bad numbers
in mathematics lessons or saying mental prayers (Fischer-Terworth, 2010).
Obsessive-compulsive disorder in children and adolescents
Table 4 - Frequent obsessions and compulsions in the school setting (Fischer-Terworth, 2010; n = 17)
Aggressive, religious or sexual obsessions are almost always kept in secret.
A religious obsession may be associated with the fear to call out blasphemic
thoughts in class or to be punished for thinking them. An aggressive obsession
may push a patient always to think he might injure other students. Sexual obses-
sions in adolescence involve, for instance, the fear to have some hidden homose-
xuality or the experience of intrusive images with sexual or perverse content.
Mental compulsions following those obsessions can be (a) ruminating about the
fact if one might be a bad or guilty person, (b) seeking for reassurance that ag-
gressive impulses (e.g. to stab a teacher with a knife) cannot be performed in rea-
lity, (c) doing rituals to protect others, (d) thinking good thoughts or (e) doing
praying rituals. Obsessions with dysmorphophobic content manifest themselves
in ruminating about aspects of one’s outer appearance like hair dressing, skin,
clothes or body weight. Adolescents with OCD may be prone to sense an unrea-
listic deformity of their body or their outer appearance. Corresponding compul-
sions may include repeated skin picking, hair combing or checking by compulsive
looking in a mirror (see Jenike, 1990b).
3.2 Compulsions related to reading, calculating and writingDescriptions in the literature point to the existence of a subgroup of OCD
symptoms, including checking and repeating compulsions which predominantly
139
occur in the school or learning context (Knölker, 1987; Boekhoff, 2000;
Adams, 2004; Danserau & Bouchard, 2005; Fischer-Terworth, 2010). Affecting
the basic learning activities reading, writing and calculating, they seem to cause
impairment in many patients. As disorder-related impairments and problems with
finishing homework is a major problem area in 90% of school-aged OCD patients
(Piacentini et al., 2003), it can be concluded that many difficulties refer to types
of compulsions described above. Children and adolescents with OCD may feel
compelled to reread text passages or sentences, to rewrite words or sentences or
to check calculating tasks again and again. The related compulsions can be asso-
ciated with substantial time loss and impairment of performance in tests. In the
following passage some presentations of these symptoms are described (see Knöl-
ker, 1987; Boekhoff, 2000; Fischer-Terworth, 2010).
(a) Reading. One 12-year-old girl feared obsessively about changing herself
completely (Knölker, 1987) and to become like her classmates. This fear was
linked to a repeating compulsion in the shape of a magic ritual: When she was
reading a text passage in class, she often had to read it again several times,
especially when other students were talking. She had to do the rereading toprevent the feared change of her person. In another case the obsessive fear of
making mistakes precipitated a checking compulsion performed to make sure
that everything was read. An 18-year-old student had to read one single word
repeatedly when he hadn’t read it without a mistake for the first time. He then
had to reread until he felt sure to have read every single letter (Fischer-Ter-
worth, 2010). This checking compulsion was connected to a repeating com-
pulsion revealing the OCD-typical feelings of insecurity and incompleteness
(see Rasmussen & Eisen 1992).
(b) Calculating. In compulsions related to calculating, patients can be compelled
to check and recheck the correctness of their result because they have obsessive
fears about mistakes which may lead to bad grades. Interfering thoughts linked
to magical thinking can compel a patient to repeat the calculating procedure till
he has a good thought. One student had to calculate until he had a good thoughtor till he was absolutely sure that the result was right. A 17-year-old girl had to
recalculate the same task several times, when she heard voices of other students(no hallucinations) or when she thought of something terrible (Fischer-Terworth,
2010). In that case the interference of an unwanted thought interrupted the calcu-
lating procedure by eliciting a feeling of incompleteness. As a consequence, the
thought seemed to warrant neutralization through repeating the task.
3.3 Situations and localizations associated with symptoms Obsessive-compulsive symptoms may be present in different places and si-
tuations of a typical school day. Symptoms may emerge during the lessons and
140
Life Span and Disability Fischer-Terworth C.
the breaks, on the way to or home from school as well as during homework
and exams. As symptoms often evoke feelings of shame, many patients tend
to hide their compulsions, delay them up to a later point in time or rationalize
them (Boekhoff, 2000; Fischer-Terworth, 2010). When rationalizing a com-
pulsion, patients pretend to perform them, for instance for the sake of cleanli-
ness, order or perfection disguising them as purposeful behaviors. as a result
of of such hiding behavior, parents are more likely to report significant im-
pairments concerning home and school functioning than patients (Piacentini
et al., 2003). Hiding compulsions generally leads to substantial inner tension
and feelings of shame evoked by the fear of being noticed by peers. It is not
uncommon that children and adolescents make exhausting efforts to suppress
compulsions which they must perform at home afterwards (Adams, 2004).
3.4 The identification of OCD symptoms in the school settingBefore school personel can be involved into identifying OCD symptoms,
they must acquire knowledge about the disorder, for instance, by reading literature
and attending lectures (Adams, 2004). Interventions have to be based upon the abi-
lity to recognize and react to OCD symptoms. Having extensive interaction with
students, classroom teachers and other school personel like school psychologists
or social workers can play a crucial role in identifying symptoms. Teachers may
be the first ones to become aware of compulsive behaviors. By doing unsystematic
behavior analysis, teachers can help to identify typical signs of possible symptoms
in the classroom. They can use verbal reports from classmates or keep written re-
cords to document academic, behavioral and social problems (Boekhoff, 2000;
Adams, 2004). Such typical signs are listed by Danserau and Bouchard (2005):
(a) Avoiding touching door knobs; use of tissues or handkerchiefs when
opening doors
(b) Repeated questioning for permission to leave the classroom to go to
the lavatory
(c) Repeated checking of doors, windows, light switches or written material
(d) Repeated and/or stereotypical reading of words, text passages or pages
in books
(e) Repeated writing, erasing and overwriting of letters, numbers or words
(f) Excessive and repeated questioning for reassurance
(g) Repeated and/or symmetric circling of items in multiple-choice-tasks
(h) Repeated ordering and arranging items (in an exact symmetrical way)
(i) Repeated and/or ritualized touching of items
(j) Avoidance of contact with sticky substances
141
Obsessive-compulsive disorder in children and adolescents
When a student’s behavior gives hints of possible OCD symptoms, school
staff can play an important role in gathering information (Adams, 2004). When
teachers witness obsessive-compulsive symptoms in a student, they can initiate
a trustful conversation with him integrating certain screening questions. In
such conversations, students tend to be surprised and relieved at the same time
because they do not assume that teachers can understand their compulsive be-
haviors (Boekhoff, 2000), which the students themselves mostly consider ab-
surd or even crazy.
If a student is exhibiting OCD symptoms, school personnel and parents should
share the names of psychiatrists and psychologists who are familiar with dia-
gnosing and treating pediatric OCD (Adams, 2004). School psychologists and
teachers should collaborate to identify the most crucial problem behaviors.
The psychologist can do systematic behavioral analysis serving as a basis for
possible interventions. Parents can be an important resource of information
because they may be able to tell relate experiences about symptoms which are
hidden in school and/or occur at home (Adams et al., 1994).
School social workers can play a key role in educating school personnel about
OCD, particularly in its effects on the danger of rejection and victimization of
students by peers. By staying in contact with parents, they can encourage them
to take part in the treatment process. The latter is crucial in most of the cases,
as OCD behaviors add stress to the family system (Livingston-van Noppen,
Eisen, Rasmussen, & McCarntey, 1990), and often exacerbate disturbances.
When involved into in treatment, family members will gain increased insight
into the nature of OCD, lose some feelings of guilt and build interaction pat-
terns which cause a diminishing of stress (Dyches et al., 2010). School psy-
chologists and social workers also can serve as an important link to therapists.
3.5 The impact of OCD in the school setting
3.5.1 Academic performanceWhile subclinical obsessive-compulsive personality traits like business or
precision may contribute to good academic performance, while obsessions and
compulsions definitely do not. Repeated controls, time-consuming ordering of
items or the repeated reading of texts can lead to a great amount of undone tasks
(Boekhoff, 2000). In fact, the ramifications of OCD can be enormous (Adams,
2003) as many compulsions negatively affect academic performance, especially
compulsions associated with reading, writing and calculating impair core acade-
mic tasks leading to major time loss in school exercises, homework and exams.
Compulsive repeating and checking often make it difficult or even impossible to
terminate tasks in an adequate time. Substantial deficits also arise through poor
142
Life Span and Disability Fischer-Terworth C.
concentration (Piacentini et al., 2003) and dysfunctional perfectionism. The
avoidance of situations which trigger obsessions and compulsions in school
can result in a total inability to go to school. The fear of being “detected” by
peers or negative comments of teachers can lead to secondary school anxiety.
Children and adolescents, who perform rituals before going to bed, can be phy-
sically and mentally exhausted due to a constant lack of sleep. When compulsions
such as checking are performed in the morning before school, delayed arrival in
class may be a problem (Adams, 2004). Although children and adolescents with
OCD have intelligence levels above the average, strengths often cannot unfold
because information processing is blocked by obsessions and compulsions (Knöl-
ker, 1987). Obsessions also affect normal cognition and interfere with regular in-
formation processing results. When obsessive thoughts intrude into consciousness
during the lessons, selective attention focusing on academic tasks can be impaired.
Consequently, they interfere with the ability to progress through a task or to shift
from one task to another. Fixation on a thought may delay completing school as-
signments and lead to decreased performance and poor grades. To the uninformed
observer, an obsessional thought might appear as inattention or distractibility
which may be interpreted as a lack of motivation, “daydreaming“ or noncom-
pliance. Compulsions also can be distracting, as when symmetrical ordering of
pencils repeatedly interrupts learning activities (Boekhoff, 2000).
According to neuropsychological research, OCD patients may have impair-
ments in visuo-spatial and visuo-constructive abilities, executive functions,
nonverbal memory and motor skills like coordination of hand and fingers (Wa-
litza & Wewetzer, 2004). In a PET study with n = 14 OCD patients (Kwon,
Kim, Lee, Lee, Lee, Kim, et al., 2003), cognitive deficits were positively cor-
related with symptom severity and excess metabolic activity in critical pre-
frontal and striatal areals. Additionally, children and adolescents with OCD
tend to respond anxiously to situations where impaired motor skills, often ap-
pearing as clumsiness, are visible to the teacher and peers (Boekhoff, 2000).
3.5.2 Psychosocial consequences of OCD in school-ageThe 151 patients in the sample of Piacentini et al. (2003) exhibited many
specific impairments in psychosocial functioning related to different aspects of
OCD. 90% of patients reported at least one significant OCD-related dysfunction
and nearly 50% had substantial problems. Hanna (1995) could show substantial
impairment in social competence in a sample of children and adolescents with
OCD, measured by parent ratings of the Child Behavior Checklist (CBC).
School-aged children with OCD often endure negative psychosocial con-
sequences having their origin in OCD symptoms. Being ridiculed or mistreated
by classmates frequently arises from others‘ perception that OCD symptoms
143
Obsessive-compulsive disorder in children and adolescents
are crazy (Helbing & Ficca, 2009). This notion often makes OCD patients wi-
thdraw from peers. OCD patients tend to have negative relationships to peers,
while low self-esteem and feelings of anxiety and shame make it difficult for
them to make friends. In the sample of Storch et al. (2006), 27% of OCD patients
reported peer victimization like physical attacks and social assaults like the ex-
clusion from a group. A correlation was found between peer victimization, lone-
liness and depression. Furthermore, being caught in obsessions and compulsive
rituals can take away time which normally could be spent with friends and hob-
bies. Symptoms like the fear of being touched as well as the fear that such rituals
might become visible for others, can be a hint for establishing good peer-rela-
tionships and friendships (Adams, 2004).
Consequently, social relationships are often restricted to the family. Patients’
relationships to their children are mostly described as good, but, however, in many
cases they seem to be ambivalent. Most of the parents are strongly involved re-
garding OCD symptoms. This may be the case through feeling guilt or responsi-
bility for childrens’ problems. As family members frequently restrict and adapt
their lives around a child’s OCD symptoms, they tend to become emotionally ove-
rinvolved or may criticize and resent the child. Such reactions can create feelings
of isolation and embarrassment, increase stress, exacerbate symptoms and trigger
family conflicts. Parents of children with OCD often have decreased confidence
in their children, and show increased levels of incendiary emotions. In families,
visibly escalated emotional expression, so called high-expressed emotions, can
maintain maladaptive functioning and contribute to relapse or exacerbations of
the child’s OCD (see Livingston-van Noppen et al., 1990; Dyches et al., 2010).
3.6 The role of teachersThe patients interviewed by Boekhoff (2000) and Fischer-Terworth (2010)
were also asked about teachers’ behaviors in the context of OCD. According to
the results, teachers did not recognize obsessions and compulsions in most of the
cases, and - as a logical consequence - didn’t react on them. The major reason for
that is the fact that patients make relevant efforts to hide symptoms which are perse difficult to recognize. Furthermore, hiding and rationalizing can be so “effi-
cient” that OCD-behaviors often resemble normal behaviors. As teachers may
have insufficient knowledge about psychiatric disorders like OCD, symptoms are
not easy to detect. When being told about the OCD-related problems by their stu-
dents or parents, many teachers made an effort to help. Several children and ado-
lescents with OCD wanted their teachers to acquire knowledge to be able to
recognize symptoms and to initiate help. But, however, for the vast majority of
patients it was crucial to take action themselves and to tell their teachers about
their OCD (Boekhoff, 2000; Fischer-Terworth, 2010).
144
Life Span and Disability Fischer-Terworth C.
3.7 The effects of treatment on academic functioningTreatment with serotonin reuptake inhibitors (SRIs) and cognitive-behavioral
therapy (CBT) may also target academic performance. Antidepressant medi-
cation is likely to affect cognitive performance helping to redirect attention
away from symptoms to academic tasks. According to the neuropsychological
study of Kang, Kwon, Kim, Youn, Park, Kim et al. (2003), cognitive deficits
related to OCD can improve with SRI treatment. According to the results, the
improvement also correlates with a reduction of symptoms and normalization
of previously altered metabolic activity in the striatal area. CBT can help to
refocus behavior away from compulsions towards adaptive behaviors like
school tasks (see Schwartz et al., 1992).
3.8 Educational interventions As the Individuals with Disabilities Education Act of 1997 (IDEA‘97) em-
phasizes the importance of positive behavioral interventions and supports for
students with disabilities, Adams (2004) suggests that school personnel should
refer children or adolescents with at least moderate OCD to the so called referralor instructional assistance team (PIAT). PIAT can consider strategies to support
the student or initiate a detailed assessment for potential special education ser-
vices. Students with severe school-related impairment may require intensive ser-
vices like adaptations in the classroom environment provided under section 504of the Rehabilitation Act of 1973. Psychiatrists and clinical psychologists with
appropriate training have to be responsible for providing CBT and/or medication
for patients with pediatric OCD. School psychologists or social workers should
maintain in contact with the student, his parents and the clinicians. It is their task
to support the student and his family, (e.g. by providing information for diagnosis
and treatment). Communication among all parties will be essential to evaluate
and adjust treatment when necessary (Adams, 2003).
(a) General suggestions. Boekhoff (2000) describes disorder-unspecific
educational interventions generally decreasing students‘ distress and pressure to
perform. Such interventions can be helpful for all students contributing to the
prevention of stress and psychiatric disorders. For students with a tendency to-
wards perfectionism, encouragement to put less emphasis on grades may be hel-
pful (Boekhoff, 2000). Furthermore, it is important to focus on students‘
strengths and talents. The latter contributes to stabilize self- esteem in school-
aged psychiatric patients including those with OCD. It also makes sense to teach
social skills and to help children to develop coping strategies to deal with di-
stressing social situations (Adams, 2003). Talking about topics like anxiety and
psychiatric disorders in class and/or implementing anxiety prevention programs
can help to reduce peer victimization and to increase acceptance of patients by
145
Obsessive-compulsive disorder in children and adolescents
peers. Additionally, the organization of presentations on OCD and other psy-
chiatric disorders in school can promote psychoeducation of students, teachers
and parents (Boekhoff, 2000; Adams, 2004).
(b) Transient modifications. Before patients have access to treatment, Adams
(2004) as well as Danserau and Bouchard (2005) suggest considering educa-
tional supports to decrease distress and to facilitate functioning in school, espe-
cially in the case of school-related compulsions. In this approach, the student
and his therapist may be involved in designing an individual modification plan.
In CBT, however, symptoms have to be treated at the same time with the aim
to enable the student to learn under normal conditions again. With successful
treatment, school-based OCD symptoms may lessen to the extent that at least
some supports can be reduced or eliminated step by step (Adams, 2004).
When compulsions associated with writing are a problem, a student with
OCD may transiently be allowed to write in italics or to use a laptop. To reduce
the functional importance of writing compulsions, only the content, rather than
the appearance of the written material should be graded. In the case of repea-
ting compulsions associated with reading, the amount of reading tasks may be
reduced. In cases of social anxiety associated with reading, tasks involving
reading aloud before class should be cancelled. When OCD leads to problems
in exams because of time loss, students may be given more time to do written
exams which they may be allowed to do in a separate room. Furthermore, oral
exams or multiple-choice-tests could replace written ones. If multiple-choice-
tests elicit symmetry compulsions like the urge to circle items painstakingly
exact or to delete non-symmetrical circles, it could be permitted to write an-
swers on the paper. When students are given additional time to do exams, a
date to hand in the exam at a designated point in time should be fixed in order
to structure the working process (Adams, 2004; Danserau & Bouchard, 2005).
(c) Educational interventions supporting CBT. Only through sustained beha-
vior modification at home and at school, can OCD patients can maintain their
therapeutic progress gained in CBT. When being supervised by a clinician, school
psychologists, social workers or even teachers may be involved into CBT exer-
cises (Boekhoff, 2000). For instance, they may encourage students to refrain from
performing compulsions and to refocus on adaptive behaviors. Educational in-
terventions, however, can also include facilitate exposure and response preven-
tion. In some cases of reading compulsions, reading aloud before class may serve
as a successful response prevention exercise as the compulsion to repeat passages
may be overridden. PC programs like Microsoft PowerPoint which present text
passages on the screen continuously and without interruption, can be an effective
tool to facilitate response prevention for that type of compulsion.
146
Life Span and Disability Fischer-Terworth C.
The process of getting stuck which leads to repetitive reading may then be pre-
vented (Danserau & Bouchard, 2005). According to the suggestions for ac-
commodating students with OCD of Packer, Challenging Kids, Inc. (2004),
Helbing and Ficca (2009) suggests that teachers may ask students if they would
like to have some redirection of their attention focus when they appear to be
distracted by obsessions.
4. Discussion
The Obsessive-compulsive disorder is a complex and severe anxiety disorder
frequently having its onset in childhood or adolescence. The disorder is now
being recognized as more prevalent than once believed. If undiagnosed and un-
treated, pediatric OCD tends to take a chronic course and to persist until adul-
thood. As children and adolescents spend much of their time at school, the
presence of OCD in the school setting should be regarded as an important subject
of scientific investigation.
Sabuncuoglu and Berkem (2006) state that children with the obsessive-
compulsive disorder experience the major part of their symptoms at home,
moreover they consider that some OCD symptoms even decrease at school.
Several OCD symptoms, of course, are not present at school, other ones may
be overridden by school-related activities. When school work serves to refocus
thoughts and behaviors away from symptoms, it may help patients to regain a
certain amount of control over them. In these cases, encouraging students to
engage in school-related activities, especially those associated with individual
talents, can serve as a therapeutic tool.
However, Sabuncuoglu and Berkem (2006) miss several important aspects.
Many OCD symptoms occur in school settings, some of them are clearly linked
to typical school-related activities. Even if symptoms in school lessen through
distraction, in most of the cases this kind of distraction is not an outcome of the-
rapeutic refocusing, attentional redirection or response prevention. The major rea-
son for students not to exhibit or report of school-related symptoms is the tendency
to hide, suppress, disguise or rationalize them. The latter consumes much energy
and can lead to mental and physical exhaustion. Once at home, children frequently
“engage in a ritualizing frenzy” (Boekhoff, 2000; Adams, 2004).
OCD is associated with many specific impairments deriving from the hete-
rogeneous nature of the disorder. Difficulties with finishing homework (Piacentini
et al., 2003) are undoubtedly one of the major school-related issues, independent
of the fact if homework is done at home or at school. Furthermore, concentration
147
Obsessive-compulsive disorder in children and adolescents
deficits resulting from neuropsychological impairment have much relevance for
academic performance.
Obviously, symptoms of obsessive-compulsive disorder can be present in
several situations and localizations of a typical school day. If a teacher suspects
OCD in a student, he first should talk to the student confidentially. In the next step,
he should convince the student that it makes sense to inform his parents and to in-
volve the school psychologist. The student then can be referred to a child psychia-
trist for assessment and be provided with support and adequate educational
interventions. Once diagnosed, school-aged children and adolescents can be treated
effectively. If untreated, affected children and adolescents are at severe risk of sym-
ptom exacerbation, a chronic, unremitting course, and the development of comorbid
disorders. Furthermore, academic impairment and peer victimization can precipitate
social withdrawal, loneliness and comorbidities like depression or social phobia.
By increasing awareness of OCD symptoms among teachers, school psy-
chologists and school social workers can make a major contribution to the
identification of children with OCD. In conjunction with clinicians, they can
make a major contribution to behavioral assessment and treatment. Early dia-
gnosis and treatment, along with the support of the family and members of the
school community, will result in a positive outcome for the child (Helbing &
Ficca, 2009). Future studies need to investigate typical school-related OCD
symptoms and their impact in the academic and social context in systematic
controlled trials. Results then can serve as a basis for the development of sub-
sequent psychological and educational interventions.
References
Adams, G. B. (2003). School personell: a critical link in the identification, as-sessment and treatment of OCD in children and adolescents. North Branford:
CT: Obsessive-compulsive foundation.
Adams, G. B. (2004). Identifying, assessing and treating obsessive-compulsive di-
sorder in school-aged children: The role of school personnel. Teaching exceptionalchildren, 37 (2), 46–53. Retrieved from http://journals.Sped. org/ EC/Archive_Ar-
ticles/VOL. 37 NO. 2. 2 NovDec 2004_TEC_Adams 37-2.pdf.11.03.2004
http://bsnpta.org/geeklog/public_html//article.php?story=OCD_School_Role
24.09.2011.
Adams, G. B., & Burke, R. W. (1999). Children and adolescents with obsessive-
compulsive disorders: a primer for teachers. Childhood Education, 76, 2-7.
148
Life Span and Disability Fischer-Terworth C.
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 psy-
chologist in identification, assessment, and treatment. School PsychologyQuarterly, 9 (4), 274-294.
American Psychiatric Association (APA, 2000). Diagnostic and statistical ma-nual of mental disorders (4th ed. text rev.). Washington, DC: American Psy-
chiatric Association.
Boekhoff, I. (2000). Zwangserkrankung und Schule: Symptome, Auswirkungenund Interventionsmöglichkeiten (OCD and school: symptoms, impact and in-
terventions). Hausarbeit zur 1. Staatsprüfung für das Lehramt an Grund und
Hauptschulen. Hildesheim: Universität Hildesheim.
Danserau, V., & Bouchard, G. (2005). Le trouble obsessif-compulsif chez lesenfants: quel est le role de l´ enseignant? (OCD in children : what is the role
of the teacher ?). Retrieved from http:/www.viepédagogique,gouv.qc.ca/arti-
cles/ trouble_obsessiv_compulsif.pdf. 11.03. 2004.
Dyches, T. D., Leininger, M., Heath, M. A., & Prater, M. A. (2010). Under-
standing obsessive-compulsive disorders in students: symptoms and school-
based interventions. School Social. Work Journal, 34 (2), 35-55.
Fischer-Terworth, C. (2010). Zwangsstörungen bei Kindern und Jugendlichen:Krankheitsbild und psychosoziale Auswirkungen (OCD in children and adole-
scents: phenomenology and psychosocial impact). Saarbrücken: vdm Verlag.
Fischer-Terworth, C., & Probst, P. (2009). Obsessive-compulsive phenomena
and symptoms in Asperger’s disorder and High-functioning Autism: an eva-
luative literature review. Life Span and Disability, 12 (1), 5-27.
Geller, D. A. (2006). Obsessive-compulsive and spectrum disorders in children
and adolescents. The Psychiatric Clinics of North America, 29 (2), 353-370.
Geller, D. A., Biedermann, J., Jones, J., Shapiro, S., Schwartz, S., & Park, K.
S. (1998). Obsessive-compulsive-disorder in children and adolescents: a re-
view. Harvard Review of Psychiatry, 5, 260-273.
149
Obsessive-compulsive disorder in children and adolescents
Gentile, S. (2011). Efficacy of antidepressant medications in children and ado-
lescents with obsessive-compulsive disorder: a systematic appraisal. Journalof Clinical Psychopharmacology, 31 (5) 625-32.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Riddle, M. A., & Rapoport,
J. L. (1991). Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS),2nd ed. New Haven: Connecticut Mental Health Centre.
Hanna, G. L. (1995). Demographic and clinical features of obsessive-compul-
sive disorder in children and adolescents. Journal of the American Academyof Child and Adolescent Psychiatry, 34, 19-27.
Helbing, M. L., & Ficca, M. (2009). Obsessive-compulsive disorder in school-
aged children. The Journal of School Nursing, 25 (1), 15-26.
Hohagen, F., Rasche-Räuchle, H., Winkelmann, G., König, A., Münchau, N.,
Geiger-Kabisch, C., Käppler, C., Rey, E., Aldenhoff, J., Hand, I., & Berger,
M. (1997). Ergebnisse einer Multi-Center-Therapiestudie bei Zwangsstörun-
gen: Verhaltenstherapie und Placebo gegen Verhaltenstherapie und Fluvoxamin
(Results of a multi-center treatment trial in OCD: behavior therapy plus pla-
cebo versus behavior therapy plus fluvoxamine). In F. Hohagen & D. Ebert
(Ed.), Neue Perspektiven in Grundlagenforschung und Behandlung der Zwan-gsstörungen (New perspectives in basic research and treatment of OCD) (pp.
93–124). Freiburg i.B.: Ein Solvay-Arzneimittel ZNS-Service.
Hollander, E., & Chapman, A. (1997). Erkrankungen des Zwangsstörungs-
Spektrums. In F. Hohagen & D. Ebert (Eds.), Neue Perspektiven in Grundla-genforschung und Behandlung der Zwangsstörungen (pp. 125-148) [Book
chapter in German]. Freiburg i.B.: Ein Solvay Arzneimittel ZNS Service.
Honjo, S., Hirano, C., Murase, S., Kaneko, T., Sugiyama, T., Ohtaka, K., Ao-
yama, T., Takei, Y., Inoko, K., & Wakabayashi, S. (1989). Obsessive–Com-
pulsive Symptoms in childhood and adolescence. Acta PsychiatricaScandinavica, 80, 83-91.
Huyser, C., Veltman, D. J., de Haan, E., & Boer, F. (2009). Pediatric obses-
sive-compulsive disorder- a neurodevelopmental disorder? Evidence from neu-
roimaging. Neuroscience & Biobehavioral Reviews, 33 (6), 818-830.
150
Life Span and Disability Fischer-Terworth C.
Jans, T., & Wewetzer, C. (2004). Verlauf von Zwangsstörungen mit Beginn im
Kindes- und Jugendalter (Course of OCD with onset in childhood and adole-
scence). In C. Wewetzer (Ed.): Zwänge bei Kindern und Jugendlichen. Obses-sive-compulsive disorder in children and adolescents (pp. 118-135). Göttingen:
Hogrefe.
Jenike, M. (1990a). Drug treatment of obsessive-compulsive disorder. In M. Je-
nike, L. Baer & W.E. Minichiello (Eds.), Obsessive-compulsive disorders: theoryand management (pp. 249-282). St. Louis: Mosby.
Jenike, M. (1990b). Illness related to Obsessive-compulsive disorder. In M. Je-
nike M. L. Baer, & W. E. Minichiello (Eds.), Obsessive-compulsive disorders:theory and management (pp. 39–60). St. Louis: Mosby.
Jenike, M. (2004). Obsessive-compulsive disorder. New England Journal of Me-dicine, 350, 259-265.
Jenike, M., Baer, L., & Minichiello, W. E. (1990). Obsessive-compulsive disor-ders: theory and management. St. Louis: Mosby.
Kalra, S. K., & Swedo, S. E. (2009). Children with obsessive-compulsive di-
sorder: are they just “little adults”? The Journal of Clinical Investigation, 119(4), 737-746.
Kang, D. H., Kwon, J. S., Kim, J. J., Youn, T., Park, H. J., Kim, M. S., Lee, D.
S., & Lee, M. C. (2003). Brain glucose metabolic changes associated with neu-
ropsychological improvements after 4 month of treatment in patients with ob-
sessive-compulsive disorder. Acta Psychiatrica Scandinavica, 107, 291-297.
Kircanski, K., Peris, T. S., & Piacentini, J. C. (2011). Cognitive-behavioral the-
rapy for obsessive-compulsive disorder in children and adolescents. Journal ofClinical Child and Adolescence Psychiatry, 20 (2), 239-254.
Knölker, U. (1987). Zwangssyndrome im Kindes - und Jugendalter (Obses-
sive-compulsive syndromes in childhood and adolescence). Göttingen: Van-
denhoeck & Ruprecht.
Kwon, J. S., Kim, J. J., Lee, D. W., Lee, J. S., Lee, D. S., Kim, M., Lyoo, K.,
Cho, M. J., & Lee, M. C. (2003). Neuronal correlates of clinical symptoms and
151
Obsessive-compulsive disorder in children and adolescents
cognitive dysfunction in obsessive-compulsive disorder. Psychiatric research:neuroimaging, 122, 37-47.
Livingston-van Noppen, B., Rasmussen, S. A., Eisen, J., & McCarntey, L.
(1990). Family function and treatment in obsessive-compulsive disorder. In M.
Jenike, L. Baer & W. E. Minichiello (eds.), Obsessive-compulsive disorders:theory and management (pp. 325-340). St. Louis: Mosby.
March, J. S., Franklin, M., & Foa, E. (2005). Cognitive-behavioral psychothe-
rapy for pediatric obsessive-compulsive disorder. In E.D. Hibbs & P. S. Jensen
(Eds.), Psychosocial treatments for child adolescent disorders:empirically basedstrategies for clinical practice (pp. 121-142). Washington, DC: American Psy-
chological Association.
March, J. S., & Leonard, H. L. (1996). Obsessive-compulsive disorder in chil-
dren and adolescents: A review of the past 10 years. Journal of the AmericanAcademy of Child and Adolescent Psychiatry, 34, 1265-1273.
March, J. S., Leonard, H. L., & Swedo, S. E. (1995). Pharmacotherapy of ob-
sessive-compulsive disorder. Child and Adolescent Psychiatric Clinics of NorthAmerica, 4, 217-236.
March, J. S., & Mulle, K. (1998). OCD in children and adolescents: A cogni-tive-behavioral treatment manual. New York: Guilford Books.
Mayring, P. (2008). Qualitative Content Analysis [28 paragraphs]. Forum Qua-litative Sozialforschung/Forum: Qualitative Social Research, 1(2). Retrieved
from http://www.qualitative-research.net/index.php/fqs/article/view/1089, 20-
02-2010.
McDougle, C. (1992). The pharmacotherapy of treatment-resistant obsessive-
compulsive disorder. In I. Hand, W. K. Goodmann & U. Evers (Eds.), Zwan-gsstörungen: Neue Forschungsergebnisse [Book chapter in German] (pp.
152-156). Heidelberg: Duphar.
McGough, J. J., Speier, P. L., & Cantwell, D. P. (1993). Obsessive–compulsive
disorder in childhood and adolescence. School Psychology Review, 22, 243-51.
152
Life Span and Disability Fischer-Terworth C.
Moll, H. G., Hüther, G., & Rothenberger, A. (1999). Neurobiologische Model-
lvorstellungen zu Entstehung und Aufrechterhaltung von Zwängen/ Zwangsstö-
rungen (Neurobiological concepts concerning pathogenesis and maintenance of
obsessive-compulsive disorder). In H. Reinecker, R. Halla & A. Rothenberger
(Eds.), Zwangsstörungen: Grundlagen, Zwänge bei Kindern, Psychotherapie(OCD: basic facts, OCD in children, psychotherapy) (pp. 46-60). Lengerich: Pabst.
Montgomery, S. A., Fineberg, N., & Montgomery, D. (1992). Phenomenology
and differential diagnostic status of obsessive-compulsive disorder. In I. Hand,
W. K. Goodmann & U. Evers (Hrsg.), Zwangsstörungen: Neue Forschungser-gebnisse (S.15–23). Heidelberg: Duphar.
Nestadt, G., Grados, M., & Samuels, J. F. (2010). Genetics of obsessive-com-
pulsive disorder. The Psychiatric Clinics of North America, 33 (1), 141-148.
Packer, L. E., & Challenging Kids, Inc. (2004). Tips for accommodating stu-dents with obsessive-compulsive disorder. Retrieved October 15, 2008, from
http://www.tourettesyndrome.net/Files/tips_ocd.pdf.
Piacentini, J., Bergmann, L., Keller, M., & McCracken, J. (2003). Functional
impairment in children and adolescents with obsessive-compulsive disorder.
Journal of Child and Adolescent Psychopharmacology, 13, 61-69.
Probst, P., Asam, U., & Otto, K. (1979). Psychosoziale Integration Erwachse-
ner mit initialer Zwangssymptomatik im Kindes- und Jugendalter (Psychoso-
cial integration of adults with initial obsessive-compulsive symptoms).
Zeitschrift für Kinder- und Jugendpsychiatrie, 7, 106-121.
Rasmussen, S. A., & Eisen, J. (1992). The epidemiology and differential dia-
gnosis of obsessive-compulsive disorder. In I. Hand, W. K. Goodmann & U.
Evers (Eds.), Zwangsstörungen: Neue Forschungsergebnisse (pp. 1-14). Hei-
delberg: Duphar.
Sabuncuoglu, O., & Berkem, M. (2006). The presentation of obsessive-com-
pulsive-disorder across home and school settings: A preliminary report. SchoolPsychology International, 27, 248. doi: 10.1177/0143034306064551.
http://spi.sagepub.com/content/27/2/248
Saxena, S., Brody, A. L., Schwartz, J. M., & Baxter, L. R. (1998). Neuroima
153
Obsessive-compulsive disorder in children and adolescents
ging and frontal-subcortical circuitry in obsessive-compulsive disorder. BritishJournal of Psychiatry. Supplement (35), 26-37.
Schwartz, J. M., Martin, K. M., & Baxter, L. R. (1992). Neuroimaging and cogni-
tive-biobehavioral self-treatment for obsessive-compulsive disorder: practical and
philosophical considerations. In I. Hand, W. K. Goodmann & U. Evers (Eds.),
Zwangsstörungen: Neue Forschungsergebnisse (pp. 82-101). Heidelberg: Duphar.
Steketee, G., & Piggott, T. (2006). Obsessive-compulsive disorder: the latestassessment and treatment strategies. Kansas City: Compact Clinicals.
Storch, E. A., Ledley, D. R., Lewin, A. B., Murphy, T. K., Johns, N. B., Goodman
W.K. & Geffken G.R. (2006). Peer victimization in children with obsessive-
compulsive disorder: Relations with symptoms of psychopathology. Journal ofClinical Child and Adolescent Psychology, 35, 446-455.
Swedo, S. E., Leonard, H. L., & Rapoport, J. L. (1990). Childhood-onset ob-
sessive-compulsive disorder. In M. Jenike, L. Baer & W. E. Minichiello (Eds.),
Obsessive-compulsive disorders: theory and management (pp. 28-38). St.
Louis: Mosby.
Swedo, S. E., Rapoport, J. L., Leonard, H. L., Lenane, M., & Cheslow, D. (1989).
Obsessive-compulsive disorder in Children and adolescents: clinical phenome-
nology of 70 consecutive cases. Archives of General Psychiatry, 46, 335-341.
Valderhaug, R., & Ivarsson, T. (2005). Functional impairment in clinical sam-
ples of norwegian and swedish children and adolescents with obsessive–com-
pulsive disorder. European Child and Adolescent Psychiatry, 14, 164-73.
Walitza, S., Melfsen, S., Jans, T., Zellmann, H., Wewetzer, C., & Warnke, A.
(2011). Obsessive-compulsive disorder in children and adolescents [Article in
German]. Deutsches Ärzteblatt international, 108, 173-179.
Walitza, S., Wendland, J. R., Rosenblatt, E., Warnke, A., Sontag, T. A., Tucha, O.,
& Lange, K. W. (2010). Genetics of early onset Obsessive-compulsive disorder
[Article in German]. European Child & Adolescent Psychiatry, 19 (3), 227-235.
Walitza, S., & Wewetzer, C. (2004). Genetische Befunde und weitere neurop-
sychobiologische Befunde zur Genese der Zwangsstörung (Genetic and further
154
Life Span and Disability Fischer-Terworth C.
neuropsychobiological findings concerning the pathogenesis of OCD). In C.
Wewetzer (Ed.): Zwänge bei Kindern und Jugendlichen (Obsessive-compul-
sive disorder in children and adolescents) (pp. 64-73). Göttingen: Hogrefe.
Wewetzer, C. (2004a). Epidemiologie der juvenilen Zwangsstörung (Epide-
miology of pediatric OCD). In C. Wewetzer (Ed.), Zwänge bei Kindern undJugendlichen (pp. 23-28). Göttingen: Hogrefe.
Wewetzer, C. (2004b). Pharmakotherapie der Zwangsstörung bei Kindern und
Jugendlichen (Pharmacological treatment of OCD in children and adolescents).
In C. Wewetzer (Hrsg.): Zwänge bei Kindern und Jugendlichen (pp. 108 –
117). Göttingen: Hogrefe.
Wewetzer, C. & Klampfl, K. (2004). Phänomenologie der juvenilen Zwan-
gsstörung (phenomenology of pediatric OCD). In C. Wewetzer (Ed.), Zwängebei Kindern und Jugendlichen (pp. 29-46). Göttingen: Hogrefe.
155
Obsessive-compulsive disorder in children and adolescents