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OCD in Children
Obsessive/compulsive Disorder (OCD) affects children, adolescents and adults. However, there is a growing belief that OCD that occurs at a very young age may be a different type to that which affects older people. The description below is a general one, covering OCD. Specific problems as they affect children and adolescents will be looked at in part two of this article.
What is OCD?
OCD usually means that the affected person suffers from obsessions and compulsions. Less frequently the person may experience one but not the other.
Obsessions are intrusive unwanted thoughts, ideas, urges, impulses or worries that repeatedly run through a person's mind. Almost by definition these will be alarming or repugnant. They may include:
· vivid images of killing or in some way abusing a loved family member;
· worries about dirt, germs, infection or contamination (affecting the person themselves or family members);
· recurrent fears that certain activities have not been completed properly (even after countless repetitions);
· a need for certain objects (or even people) to be in 'correct' positions or places before activities can be undertaken;
· blasphemous thoughts;
· a fear that important things may be lost unless extreme care is taken;
· a fear that harm has been caused accidentally (running somebody over in the car or leaving harmful objects around);
· repetitive counting and weird or frightening visual images.
· Having lucky or unlucky numbers;
· Intrusive nonsense sounds, words or music, which the person will be aware is produced by him- or herself, not by an outside force.
Other fears, which are sometimes on the line between a phobia and an obsession, might concern worries about the shape, functioning or smell of body parts. Obsessions have also been known to swing between various foci, where sometimes one thing and sometimes another is viewed as more important/dangerous/in need of ritual countering.
Compulsions (often known as rituals) are repeated behaviours that are usually performed to reduce the discomfort or anxiety generated by obsessive thoughts. This might be washing, checking, going back on journeys or sorting things. This is invariably excessive, usually (not invariably) having to be performed in a very precise manner, and may be repeated many, many times until the person feels it is 'right'. Sometimes, behaviour does not seem to be directly related to relieving an obsession, but those performing the ritual may still experience an overwhelming need to perform it. The most common compulsions described to Anxiety Care are:
· excessive hand washing, bathing or showering;
· cleaning household equipment or furniture;
· avoiding 'contaminated' or 'dangerous' objects or substances (commonly dog faeces, knives, asbestos, etc.);
· checking water, electric and gas taps; windows, cupboards and doors;
· repeatedly checking that nothing 'bad' has happened or accidents have been caused and demanding reassurance about this.
Less common ritual behaviours include:
· dressing in a precise and predetermined fashion;
· entering or leaving the home or car in the 'correct' way (which may seem bizarre to an observer), and repeating these behaviours.
Less common still are rituals concerning hoarding, including an inability to throw things away without excessive checking; obsessive reading; and performing certain acts like dressing, bathing or crossing roads very slowly.
If obsessions and compulsions do not take up more than an hour a day and are not significantly interfering with life function, then this person has OC symptoms but would not be diagnosed as having OCD.
Both obsessions and compulsions may vary greatly in duration and intensity among individuals suffering them. They may be a mild irritant, a waxing and waning problem or totally disabling and life consuming. Depression can be a contributory factor to the disorder or become a problem as a response to the level of handicap involved.
People with OCD might also experience panic. This is likely to be in response to a stimulus, e.g. seeing blood, dog faeces or a sharp knife, much as with a phobic response. If these panics come out of nowhere, for no apparent reason and the sufferer is afraid of the symptoms of panic rather than the consequences of the panic-causing event, as would be true of OCD panic, it might be worth checking with a mental health professional about the possibility of there being co-current Panic Disorder. Having said that, some people with OCD are loath to admit to extreme responses to a stimulus, particularly if they are deeply ashamed of their problem.
OCD seems to affect 2-3%of adults in the western world. There is research that suggests that symptoms at a sub-clinical level might be as high as 18-19%, and mildly obsessive behaviour - even to the extent of eccentricity - is extremely common. One study suggests that the probability of an individual suffering from OCD at some time in his or her life is over 5%.
CAUSES OF OCD
There has been a good deal of research carried out over the past few years regarding the causes of OCD. It has been speculated that there might be several kinds of OCD and that, in particular, OCD that starts in childhood, as will be discussed, may be different from that which begins in adulthood.
One cause that is gaining ground concerns the probability that there is a level of brain dysfunction in many OCD sufferers.
This does not mean that people with this problem have damaged brains or that their reasoning functions are inferior to those who do not have OCD.
The chemical messenger, Seretonin seems to be heavily involved in OCD and may also play a part in other anxiety disorders. Seretonin is a chemical called a neurotransmitter that allows nerve cells to communicate with each other by working in the space between nerve cells, called the synaptic cleft. According to research, Seretonin is involved with biological processes such as mood, aggression, sleep, appetite and pain. It also seems that Seretonin is capable of connecting to nerve cells in the brain in many different ways and so can cause many different responses. It is not even fully established if it is all or part of the Seretonin chemical or another chemical entirely acting on it; or a malfunction in one or more of the receptors in the brain that Seretonin attaches to that causes the OCD problems.
Brain scans have also shown that people with OCD often have abnormalities within the brain, particularly in the orbital cortex (the part of the brain above the eyes) and in deeper structures such as the Basal Ganglia and Thalmus. This research suggests that the communication between these parts of the brain is not functioning correctly. Basically, when anxiety rises in the OCD sufferer, a circuit of inappropriate response happens between these parts of the brain.
As the deeper, primitive part of the brain is not the part that is involved with reasoning, it is not possible to 'talk yourself' out of an over response. As the various parts of the brain have different levels of priority and urgency, the 'message' being sent can cause great confusion to the reasoning brain, the Cortex.
For example, the Thalmus processes sensory images coming to the brain from the rest of the body, while the Caudate Nucleus, part of the Basal Gangli in the centre of the brain controls and sorts sensory information and does thought filtering. When these messages are being misinterpreted, 'misfiring', the thinking part of the brain is naturally confused and is responding chemically to a threat perceived by the primitive, non-reasoning part of the brain with rational doubt of the threat's danger, but a major need to response as if the danger is real. In effect, the Caudate Nucleus is letting unnecessary thoughts and impulses through to the Cortex where the thoughts and emotions combine; and an over active Cingulate Nucleus at the brain's centre, which helps shift attention from one thought or behaviour to another, becomes over active and gets stuck on certain behaviours, thoughts or ideas. The Cingulate is that part of the brain which tells the OCD sufferer that something terrible will happen if the compulsions are not carried out.
So, with the Thalmus sending messages that makes this person (probably very uncomfortably) aware of everything around him or her and the Caudate Nucleus opening the floodgates to intrusive thoughts, the Cortex is perceiving major problems that feed in to the 'fight or flight', or major danger response. The Cingulate Gyrus then demands that compulsions are carried out to relieve the terrible anxiety feelings.
· IT CAN BE SEEN FROM THIS THAT, TRYING TO 'THINK' ONESELF FREE OF OCD WITHIN THE PROBLEM AND USING THE PROBLEM'S OWN PARAMATERS, IS NOT A REASONABLE OPTION.
· IT IS IMPORTANT TO BE ABLE TO DIFFERENTIATE BETWEEN WHAT THE PRIMITIVE AND RATIONAL BRAINS ARE SAYING IS THE TRUE SITUATION.
· BEAR IN MIND THAT THE PART OF THE BRAIN RESPONSIBLE FOR OCD, FUNCTIONS VERY MUCH ON THE SAME EMOTIONAL LEVEL AS THAT OF A TWO YEAR OLD. REASONED ARGUMENT IS, THEREFORE, POINTLESS. A FURTHER PROBLEM IS THAT PEOPLE WHO ARGUE WITH TWO YEAR OLDS END UP ARGUING AT THE SAME LEVEL AS THE INFANT WHICH JUST CAUSES EXCESSES OF EMOTION AND NEVER SOLVES ANYTHING.
Within the groups, we sometimes talk about the OC response as a huge two-year-old. It cannot be reasoned with, but it demands notice and is powerful enough to insist. Then, as with any irrationally demanding two-year-old, one has to use techniques to win it round or divert its needs. To this end, gradually increasing exposure to the problem may be used, but it should never be forgotten that this OC response is not malign, it means no harm, but it cannot be reasoned with intellectually. So anyone experienced in dealing with small children might usefully include these child-teaching techniques, or appropriate versions of them, as part of a recovery programme. Common sense is a very useful tool in combating
Some research points to the likelihood that OCD sufferers will have a family member with the problem or with one of the other 'OCD Spectrum' of disorders. These are: body dysmorphic disorder (excessive concern about minor or imagined defects in appearance), hypochondriasis (fear of having a serious disease despite tests and reassurance by medical professionals), binge eating and trichotillamonia (pulling out scalp hair, eyebrows, eyelashes, body hair, even that of others such as children or pets). However the possibility that it is inherited genetically is not conclusive. It does not follow, for example, that identical twins will both have OCD (although there is an increased chance), so genetics cannot be entirely to blame.
One American study suggested that up to 30% of teenagers with OCD had a member of the immediate family with the problem or with obsessive symptoms. Other studies tend to suggest that if a sufferer's OCD began in adulthood there is less chance of this person's offspring contracting it than if the problem was contracted in childhood, specifically if the latter is the type of OCD that tends to start in childhood (if there are different types).
Other research suggests that if one parent has OCD the chances of the child having it are between 2% and 8%. Here again, if the parent has family members with the problem, the chances of the child contracting it increase and if the parent has no family history of OCD, they decrease. A point to bear in mind concerning children is that OCD can involve increased stress and poor eating habits, particularly if the problem relates to food. Children with OCD might then not do too well physically and be prone to stress related problems like headache and upset stomach.
A streptococcal infection of the throat is known to occasionally result in the body confusing healthy cells with the infection and causing cellular damage. If this has happened with the brain, the body's infection fighting system can attack the outside of nerve cells in the Basal Ganglia part of the brain with the result that OCD symptoms occur. Some research suggests that these symptoms don't seem to last very long and the occurrence of this 'infection OCD' seems to be very rare.
'Strep throat' is a specific infection usually found in children, and a general 'sore throat' does not mean this infection is present. Symptoms of strep vary a lot but can include a bright red throat, high fever, tender and swollen lymph nodes under the jaw, ear pain, white pus on the tonsils and dark red spots on the back of the throat. Blocked or runny nose is not usually present and some children hardly get any symptoms. Scarlet fever is one form of strep infection and in this case there will be a fine red rash on the body, probably starting with the upper body. Strep infection can also lead to rheumatic fever or kidney problems when not treated. Penicillin seems to be the treatment of choice at present. If OCD results from a strep throat infection, the symptoms seem to start quickly, probably within one or two weeks.
People with depression sometimes develop OC symptoms, and those with OCD very often develop depression. Dealing with both together is very difficult without professional help and it is notoriously difficult to undertake an exposure programme while the depression is high.
This is the theory that states that disturbances in early sexual or general development and unconscious wishes are at the heart of OCD. Regarding development, the theory is that conflict between the thinking and reasoning part of the mind and the part that wants it's own way is dealt with in an unstable way by the child and that causes mental problems in later life. An example might be a compulsive checker of taps who, according to this theory, wanted to flood the house as a child. With unconscious wishes, the theory could be that, for example, the person who fears running over people in his car, really wants to do this. To keep the awareness out of his consciousness he uses a huge amount of energy that gives the thought an obsessional quality. These theories are not given much weight nowadays, although it is always useful to be aware of the role of guilt feelings in OCD.
Guilt and shame seem to occur strongly in some people's OCD, particularly that of young people. 'Tendency' also seems to play a large part in this disorder, as in children inheriting a disposition towards OC problems or learning anxiety and guilt from parents or 'significant other' people in their lives. Why some people have a tendency towards neurosis and others don't is very difficult to say. Many of us learn to feel guilty about our natural bodily needs and expressions from a very early age and it can be said that guilt and feeling over-responsible is endemic to obsessive people of our culture.
The cause of OCD is probably a mix of many factors described above, including neurobiological, environmental influences and the way we think.
Part 2 - Childhood OCD
It is generally estimated that up to one pre-adolescent child in two-hundred has OCD, although some studies suggest it could be as high as 3-4%. Studies that favour the lower totals do, however, suggest that up to 3% of adolescents will be having obsessional symptoms that will be irritating, even alarming, but not disabling and interfering with their lives. However, it is also common in young people for vaguely obsessional symptoms to be socially acceptable within the peer group, so it is often not easy to diagnose OCD; particularly when a main area of diagnosis and help-seeking will involve how the sufferer perceives the symptoms. That is, as distressing or not, which will vary a great deal with relation to how 'different' this makes the young sufferer feel within his or age peer group. As we all understand, when a whole group behaves oddly, this behaviour is only strange and alarming to outsiders, not the members of this group, and when this behaviour becomes a majority response, this then is the norm and worries about it may become very low or non-existent.
Children as young as five or six have been seen with full-blown OCD. Between 30% and 50% of adults report that their symptoms started before or during mid-adolescence. Most studies show that male sufferers exceed female in the ratio of 3:2 with child OCD. This compares to an equal split, or slight female predominance, in OCD that starts in adulthood (a general average onset age of twenty-one). This equal split between the genders tends to start in late adolescence. These studies say that the onset of childhood OCD is between age seven and age twelve with an average of just over ten, and that most children are not seen for over two years after onset. Some studies suggest that boys tend to start earlier than girls and that some adverse event that affects the child emotionally may be involved with onset in 38-54% of cases. It is also reported that other psychiatric disorders tend to occur during the lifetime of child sufferers in 75-84% of cases.
Some research suggests that children tend to have four or five different (of each), obsessions and compulsions, over the period of disability but that compulsions only, without obsessions, are more common in young children than in adolescents. Gender or age of onset does not appear to affect the type, number or severity of OCD symptoms.
With obsessions, pre-adolescent children tend to focus on some feared catastrophic family event such as the death of a parent. They may have feelings of contamination (not necessarily feeling dirty as such), fears about their bodies, sexual fears and worries about doing the right thing. It seems, from some research and from the charity's experience, that the younger the child the more unusual or bizarre the symptoms are likely to be. Compulsions are most commonly: washing, repeating activities, checking things and putting things in order. Within Anxiety Care, putting things in order has included putting them precise distances away from each other, facing the same way or making a precise geometric shape. This should not, of course, be confused with the tendency many very young children have of ordering toys or placing them in sometimes quite complicated patterns.
These symptoms tend to wax and wane with childhood OCD and change within a spectrum of four or five different focuses as mentioned above, so it is not always easy to say, precisely, what the child is obsessing, or performing compulsive rituals, about. Young children also very often describe their obsessions as worries or fears and it can be difficult to assess whether these are in fact worries normal to the child's stage of development or obsessions.
Not unexpectedly, young children tend to involve their parents in their obsessions and compulsions a good deal. From Anxiety Care's experience, this can be just one parent. It has also been known for the other parent to be excluded almost totally, or even to be viewed, by the child, as responsible for some of the ritual. This naturally leads to family problems and can cause great unhappiness among siblings and other family members.
Any parent conscripted into supporting a young child in his or her OCD has to be very aware of the fact that there may be no end to the help demanded unless boundaries are set. OCD often takes up as much space in life as the sufferer allows it, pressing on the child's abilities to function, always ready to make more and more things difficult or impossible on particularly bad days. In the throes of this disability, the child is even more likely that an adult sufferer to see being thwarted in a need to obsess or ritualise as outrageous; and a child is usually adept at knowing how to get his or her own way with the chosen parent and to have little inhibition about doing this.
Does onset in childhood mean a different presentation of adult OCD symptoms?
There is no apparent research on the affect early onset of OCD has on the way it presents in the adult years. Experience within Anxiety Care of adult sufferers who developed the problem in early childhood as compared to those who developed it in late adolescence or early adulthood, suggests there might well be differences.
That is, some service users who have had the problem since the age of six or seven seem to have a tendency towards obsessional fears that see them helpless or abandoned, or not taken care of by the important people in their lives. This as opposed to sufferers who contracted the problem later, whose obsessions concerning significant people in their lives seem to be more about their ability to keep these people safe. There is often a severe fear of change in those contracting the problem young, any sort of change from people going away to moving the TV a few inches. This fear is not restricted to childhood OCD but, from Anxiety Care's experience, it is certainly more common in OCD that develops at an early age.
As we learn best when young, and as many of the very strong lessons we learn at this time stay with us for a lifetime, it seems more than possible that obsessional symptoms experienced during this period might continue very much unchanged into adult life, or at least remain as a tendency. That is, for example, when a member of the family leaves home, normal anxiety or depressive mood in the person who contracted OCD in childhood might align towards obsessing about feeling abandoned, while the OCD sufferer who developed the problem as an adolescent or adult might, in the same situation, 'naturally' fall in to obsessing about this person's safety when outside his or her protection.
If the age of onset does significantly affect the form obsessional symptoms take in later life, this might be a small comfort to those adults, particularly males, who perceive their 'childish' symptoms to be yet another piece of evidence in support of their belief that they are sub-standard and immature. At best, feeling incompetent is not a good starting point for the often very difficult task of undertaking a recovery programme. At worst, it can mean that the mind is set at obtaining comfort and outside support and finds it extraordinarily difficult to believe that personal effort is the way out of the OCD.
Self-esteem issues might also be involved in when, during one's life, OCD is contracted. It is common for people with OCD to have very low estimations of their own value, which makes them prone to viewing themselves as worthless and/or bad and therefore capable of doing the negative or illegal things they may be obsessing about. Young children, notoriously, also tend to see their value reflected in single achievements. That is, they may have little sense of being, generally, worthwhile people whatever they do, but base their beliefs about themselves on single acts of 'goodness' or 'badness'.
When the mind is set in this direction there are major problems because life tends to involve many more average or 'blunder' days than days when there are sparkling achievements. So the person who only feels good about him- or herself when doing something specially praiseworthy is in for a majority of days feeling second rate or worse. The child with OCD might, therefore, have feelings of worthlessness aggravating the disorder and this would have to be confronted as part of a therapeutic response.
Another self-esteem issue, often seen with users of the Anxiety Care service, is that, even when self-esteem was at a reasonable level prior to contracting the disorder, it quickly became eroded by the problem. So the child who was self-confident prior to contracting OCD might still have problems in this area afterwards.
Most research supports the idea that those contracting OCD in childhood tend to have other disorders too that may be interfering with normal development. These may be depressive problems, other anxiety disorders and behaviour disorders. Various research projects say that between 28% and 50% of children with OCD have disruptive behaviour disorders.
There are a number of disorders that come under the general heading of 'behavioural'. Symptoms will vary between mild negative, hostile and defiant attitudes through arguing, a willingness to be resentful and easily annoyed, lying, truancy, aggressive behaviour towards other children or animals, destruction of property, theft, inappropriate sexual behaviour, a general violation of, and indifference too, social rules, a lack of concern for others and a lack of remorse for bad behaviour. Diagnosis of a behaviour disorder would only be made if the child displays persistent and severe antisocial and aggressive behaviour that could not be better interpreted as a development and passing phase; and where this behaviour has lasted for more than six months.
Some level of what is known as 'oppositional behaviour' is entirely appropriate for children as they develop and the child would not be statistically normal if he or she didn't try to assert personal will and oppose the will of others from time to time, particularly the will of significant adults in this young person's life such as parents and teachers. Expert assessment is therefore essential if a parent feels that a child's behaviour is beyond normal, acceptable levels.
One of the problems with associated behaviour disorders is that the child may have poor self-esteem, a low tolerance for frustration, a depressed mood and temper outbursts, and may well blame others when things go wrong. None of these are a good starting point for an OCD recovery plan based on personal effort.
Other problems with childhood OCD might involve the need for things or activities to be perfect or in having overvalued ideas. When children are very young they do not usually care very much about making mistakes and getting things wrong. However, this does change and the need to be totally perfect in activities such as homework can be a sign of an anxiety disorder. Some young people referred to Anxiety Care have exhibited an obsessional need to make all written work, for example, 'perfect'. As this need is often barely related to reality, being much more linked to their beliefs about their abilities and what people will think of them if they 'make a mistake', their sense of what is or is not 'perfection' often involves them in, literally, hours of unnecessary work. This is not to say that wanting to be perfect is invariably a disorder; many of us have tendencies in this direction, but the non-OCD sufferer will usually have a good idea about when this is unreasonable. The OCD sufferer will probably strive longer and with much more associated anxiety and self-disgust, even when he or she understands that these perfection needs are based more in obsession that any reasonable expectation that things can be made that good.
Overvalued ideas are in that grey area between strong beliefs and delusion. The child with overvalued ideas will have an unreasonable and persistent belief in something, not to a delusional level, but which probably has some basis in reality. Anxiety Care has encountered a number of adolescents who have these beliefs related to bodily functions. For example, that a major bowel movement every day is essential to good health, where this belief has been taken to a level at which a precise amount of defecated faeces is demanded every day. This has resulted in hugely over extended visits to the lavatory, straining of the body resulting in tissue damage and the unnecessary consumption of strong laxatives. This might also be defined as illogical thinking which involves the child coming to conclusions where there are blatant contradictions or errors in the way the belief has been arrived at.
It is probably not useful trying to label a particular aspect of obsessional behaviour as naming it will not cure it, and effort could usually be put to better effect seeking out countering recovery techniques. Normal developmental problems in childhood and adolescence account for a lot of odd and extreme behaviour that would be totally unacceptable in an adult. This can be a comfort and a hindrance. It is often a hindrance when a parent becomes so used to the young person's mood swings and anti-social acts that significant increases in this behaviour are missed. It is also very common for the less able professionals to write off everything the child does as a passing phase. As the earlier intervention occurs the more likely is a recovery, such problems can be serious.
It can sometimes be difficult to accept that one's child has mental or emotional problems. Anxiety Care has encountered a fair number of parents and carers who have maintained a denial of anything being wrong well beyond any reasonable level. It can be just as difficult to challenge a mental health professional's dismissive evaluation when the parent knows, deep down, that there really is something amiss. The only advice here is to persist and risk being labelled as an over-protective parent. Too many young people have been allowed to suffer until their problem has become chronic and therefore even more difficult to counter. Some of these have made great efforts to hide their disorder but others, while not actually asking for help, have made it known in small ways that they needed it. Personal embarrassment on the part of the parent is obviously a small price to pay when a child's mental health is concerned.
People with OCD are usually offered some form of 'talking treatment' and/or medication. The talking treatments are behavioural therapy which tries to change behaviour by gradual exposure to the feared situation; or cognitive-behavioural therapy which tried to help sufferers to understand their thinking patterns, and the errors they make when processing incoming data, so that they can react differently to situations that make them obsess or ritualise. With very young children and others who have little insight into the irrationality of their thinking, this can obviously prove difficult. The article 'Thinking that gets in the way of recovery', available on this site, would be worth reading for those who feel their child has problems in this area.
Medication is usually some form of serotonin reuptake inhibitor (SSRI); or the tricyclic clomipramine. Both are anti-depressants that have been found to have a good affect on OCD. There are quite a large number of SSRI's. All are from the same 'family' but are different enough from each other for another to be tried if one doesn't work or has unacceptable side effects. Clomipramine was one of the first drugs proven to have a beneficial effect on OCD but is not prescribed now as frequently as the SSRI's. Sometimes one or other of the benzodiazepines (tranquillizers) are used to supplement the anti-depressant. There is research at the moment that some physicians are trying a mix of medications for OCD. With all medication, the side effects occur before the benefits, so if a person has waited to take medication until he or she couldn't stand feeling this bad any longer, the side effects might make him or her feel worse for a while, which might present as intolerable and result in essential medication being given up.
From Anxiety Care's experience, some people are so overwhelmed by their disorder, spending all their time defending themselves from it and terrified of it, that they do not believe that they can do anything to counter its effects. In reality, this person is living permanently at crisis level. With the mind set in this way, a response to a talking treatment alone, that required the sufferer to confront the obsessions, would probably be very poor. When medication is added, this can reduce the crisis level so that the sufferer can actually accept that the disorder is not all-powerful. The anti-depressant medication will also lift mood and offer a more positive outlook when depression is a contributing factor to the OCD.
However, many sufferers are very unwilling to take medication and many parents are unhappy with urging this form of support on their children. It is obviously a personal choice, which should include the child's choice too, but Anxiety Care has seen too many people suffering unnecessarily because of this resistance to medication. Talking help is essential, medication alone won't change patterns of behaviour and when the medication is stopped, if no talking help has been available, the odds are the disorder will return. But, as said, sometimes a person is so ill with OCD that they simply don't hear what is said to them in a talking therapy, or can't see that they can do anything personally to counter the disorder. No talking therapist can do the work for the sufferer; he or she has to do the practical activities at some point. There is also no drug or talking treatment out there that will magically take the pain away. And, in Anxiety Care's long experience, that perennial hope that 'finding out what caused it' will cure everything simply doesn't happen. People have grown old looking for the reason (usually who made me like this); and those coming to Anxiety Care who have established probable social causes through long (and often expensive) psychotherapy have not immediately recovered. At best it has started a long recovery process that still needs much support; or pointed out to them ways in which they could think or act differently in the future. No miracles at all.
About Anxiety and Depression. http://www.friendsinfo.net/anxietydepress.html
Conduct Disorder and Associated Challenging Behaviours in Children; Fact Sheets for Health Professionals
Epidemiological Information. http://www.education.ucsb.edu/~jimerson/ocd.html
Geller, Daniel et al; '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'; April 1998 37(4) 420-427;
NIDA Notes; Smoking May Lead to Anxiety Disorders in Adolescents and Young Adults. http://www.nida.nih.gov/NIDA_Notes/NNVol116N1/Smoking.html