Obsessive-Compulsive Disorder
The school nurse has unique roles in assisting students with obsessive-compulsive disorder (OCD). These roles include: identifying possible OCD; gathering information from school staff with checklists, observations, or interviews; assisting with school-based interventions to support students who have OCD; monitoring and reporting effects of medications; and serving as the school's liaison to the student's physician.
OCD is an anxiety disorder that occurs in up to one percent of children. It is characterized by recurrent and persistent thoughts and worries that are expressed in compulsive behaviors intended to reduce irrational anxiety; they sap the energy needed for schoolwork and social relationships.
One theory of causation involves an imbalance of serotonin and possibly of dopamine. Twenty to 25% of adults with OCD have a first degree relative with OCD or other anxiety disorder. Additionally, there is evidence that OCD may be triggered by pediatric autoimmune neuropsychiatric infection (PANDA). An immune response to a streptococcal infection creates lesions in the basal ganglia. It is thought that lesions in the basal ganglia, which ordinarily filters unnecessary ideas, allows these ideas to pass onto the thalamus which relays them to the frontal cortex. An "endless loop" of ideation results in OCD and tics.
The onset may be gradual or abrupt. One common expression is fear of contamination as evidenced by frequent handwashing, even scrubbing with alcohol or detergent cleansers. Students may request frequent trips to the bathroom that teachers assume are for voiding. The observant nurse who is asked to assess the student may note very chapped skin due to over-washing.
Some students may suppress their compulsive behaviors during school hours, but the resulting heightened anxiety is expressed in a frenzy of ritualistic behaviors at home. Parents are fearful, and school personnel don't understand the concern since the behavior is not seen at school.
Treatment involves medication, behavior training, and "12 step" programs. Medications include the tricyclic antidepressant clomipramine (Anafranil) [approved by the FDA for children 8 and older] and SSRIs such as Zoloft (ages 6 and older), Luvox (ages 8 and older) and Prozac (off label use) which has a long half-life. Cognitive behavioral therapy is an "exposure and response prevention" program in which the child faces the fearful situation with support, feels the fear but does not engage in the compulsion, and learns that nothing bad happens when he does not carry out the ritual. Typically, this therapy consists of 16 to 20 weekly sessions with boosters as needed. Support groups are helpful.
(Adams G. Caring for children afflicted by Obsessive-Compulsive Disorder. Presentation at National Association of School Nurses, San Diego, June 29,1998)
COMMENT: The presenter, an educational psychologist, indicated that the school nurse may receive referrals on undiagnosed children for frequent absences or inattentiveness and may observe them to be unusually tidy or repeatedly seeking reassurance.
