Up on the toilet means off with the clothing

Q. The mother of one of my patients, a 5-year-old boy, voiced concern at his annual well-child visit over his constant "need," for approximately one year now, to remove all his clothing before using the toilet to void or defecate. She recalls that this behavior began some time after he soiled himself during a brief diarrheal illness. The boy also has a history of excessive hand-washing (many times a day, for no apparent reason) and rubbing his face against his parents' arms and stomachs. He is otherwise a pleasant and healthy child.

The boy's undressing behavior began at about the age of 3½ years, then resolved, for a time, about six or seven months later. His mother reports that she has a nephew, now 12 years old, who "did the same thing."

I have discussed the problem at length with the patient's mother, and my thinking is that an evaluation for obsessive-compulsive disorder (OCD) may be in order. Would this be a reasonable course to take?

A. As is the case with many mental health diagnoses, it is important, when OCD is suspected, to, first, refer to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), for specific required diagnostic criteria and, second, recognize that the presentation of that disorder in a child may vary from the standard. The essential feature of OCD in the DSM-IV is a recurrent obsession or compulsion severe enough to be time-consuming or cause marked distress or impairment. Specifically:

It appears that this child meets diagnostic criteria for possible OCD; the removal of clothing qualifies as a compulsion that his parent recognizes as excessive and that may be considered either time-consuming or interfering with normal routine (consider the difficulty that arises when he needs to use a public bathroom!).

OCD was one believed to be relatively rare in children and adolescents, but is now estimated to affect as many as 2% of children. The diagnosis is not an exclusionary one: Other anxiety disorders, tic disorders, and disruptive behavior disorders, as well as learning disabilities, are common comorbidities of OCD.

As with many neuropsychiatric disorders, chronic waxing and waning of symptoms occurs in what is a chronic disorder. If you suspect OCD in this child, certainly refer him to a mental health professional for a complete family history, a structured interview, or psychological testing-or all of these evaluations.

Successful treatment of OCD involves both judicious use of medication and structured psychotherapy-specifically, cognitive behavioral therapy that is designed to provide the patient with the skills to master obsessive thoughts and accompanying compulsive behaviors.¹ With ongoing support from you, his primary care provider, and consistent intervention, child and family should expect a good outcome.

1. Pediatric OCD Treatment Study (POTS) Team: Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA 2004;292:1969

Marilyn Augustyn, MD

DR. AUGUSTYN is assistant professor and director of training, division of developmental and behavioral pediatrics, Boston Medical Center