School Psychology International

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The Presentation Of Childhood Obsessive–Compulsive Disorder Across

Home and School Settings: A Preliminary Report
Osman Sabuncuoglu and Meral Berkem
School Psychology International 2006; 27; 248
DOI: 10.1177/0143034306064551

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 The Presentation Of Childhood
Obsessive–Compulsive Disorder Across Home
and School Settings
A Preliminary Report

OSMAN SABUNCUOGLU and MERAL BERKEM

Department of Child Psychiatry, School of Medicine,
Marmara University, Istanbul, Turkey

ABSTRACT This study aimed to determine the exact pattern of

obsessive–compulsive disorder (OCD) symptoms in children displayed
across school and home settings. Twenty-six school children (aged 7
through 17) with OCD were tested using the Children’s Yale-Brown
Obsessive Compulsive Scale (CY-BOCS), the Clinical Global Impres-
sion (CGI) – severity subscale and a questionnaire which consists of
items serving to compare the symptoms between home and school set-
tings. The mean obsession and compulsion subscores on the CY-BOCS
were found to be 10.73 ± 3.14 and 10.88 ± 3.17, respectively, both sum-
ming up a Total score of 21.61 ± 5.52. The mean CGI-severity scores,
rated for home and school settings were 4.42 ± 0.90 and 2.42 ± 1.13
respectively, indicating a strong difference in the presentation of
OCD between those settings (t = 7.02, df = 50, p < 0.0001). No gender,
diagnosis (pure versus comorbid) and age effect (7 to ≤ 12 years versus
> 12 to 17 years) was found on the CY-BOCS and CGI-severity subscale
(Mann–Whitney U test, all p > 0.05). The presentation difference we
have noted in this study is a significant finding. Further studies
are needed to delineate the characteristics of this phenomenon with
possible implications for diagnosis, management and treatment.

KEY WORDS: child; obsessive–compulsive disorder; schools

Introduction
Childhood obsessive–compulsive disorder (OCD) is a chronic and
under-recognized psychiatric condition affecting between one and four
Please address correspondence to: Dr Osman Sabuncuoglu, Halk Cad. Emin
Ongan Sk. 11/7, 80300 Üsküdar/Istanbul, Turkey.
Email: sabuncuoglu2004@yahoo.com

School Psychology International Copyright © 2006 SAGE Publications (London,

Thousand Oaks, CA and New Delhi), Vol. 27(2): 248–256.
DOI: 10.1177/0143034306064551

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Sabuncuoglu and Berkem: Childhood Obsessive–Compulsive Disorder

percent of children and adolescents (Carter and Pollock, 2000). Lifelong

characteristics of OCD necessitates in depth understanding of child-
hood OCD in terms of age of onset, diagnosis, symptom presentation,
treatment and course of the disorder. Yet knowledge of childhood OCD
is still being accumulated, and various phenomenological dimensions
await to be determined. The manifestation of OCD may differ in
children from that of adults as it is always influenced by developmental
issues (March and Leonard, 1996). Young children may be less likely to
report their symptoms, whereas for example, bedtime rituals may
occur as near normal behaviours in their daily life (Riddle, 1998).
The symptom profile of children with OCD across home and school
settings is one of those topics which remain fairly unknown, unlike, for
example, that of Attention-Deficit/Hyperactivity Disorder. According
to the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV), the diagnosis of OCD indicates the significant inter-
ference of symptoms with school, social activities and important
relationships (American Psychiatric Association, 1994). Furthermore,
OCD is described to be severely disruptive to academic life (Adams et
al., 1994). In a study which investigated 61 children and adolescents,
it was found that incidents related to school situations commonly
triggered obsessive–compulsive symptoms (Honjo et al., 1989). In an
attempt to manage the obsessive–compulsive personality in the class-
room, the benefits of school consultation have been introduced (Parker
and Stewart, 1994). The main concern was around the problems of
school failure and the idea was that effective intervention might relieve
the stress encountered by the obsessive–compulsive traits. However, as
the emphasis was on the impact and importance of character traits, the
presentation of the symptoms of OCD in the school setting was not
mentioned as a distinct entity.
Some authors have given accounts of teachers and peers becoming
aware of children’s symptoms much later than the parents as the
symptoms become more severe (Rapoport et al., 1994). It has also been
pointed out that children with OCD may have a partial voluntarily con-
trol of symptoms in public. In one review by McGough et al. (1993),
while the expression of OCD symptoms at school is acknowledged as
rare, school psychologists and teachers are assigned to important roles
in the management of the illness. One recent study on childhood OCD
found the highest level of functional impairment at home/with family,
according to both parent and child reports on the Child OCD Impact
Scale (Valderhaug and Ivarsson, 2005).
Since schoolchildren spend one-third of their time at school on
average, the presentation of OCD in school settings is worthwhile
investigating. Our extensive literature search failed to reveal relevant
data which accurately focuses on this issue. It is of interest that a basic

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 School Psychology International (2006), Vol. 27(2)

symptom profile is still lacking today. Therefore, the aim of this study
was to delineate the presentation of OCD across home and school
settings in children and adolescents.

Methods
The study was carried out during the school year in order to collect data
regarding the school setting. At our Child Psychiatry Department, 26
consecutive cases with OCD were enrolled in the study who were
between 7 and 17 years of age. The mean age of the sample was
12.30 ± 3.31. Of the children included, 19 were boys (73.1 percent) and
seven were girls (26.9 percent). Child psychiatric diagnoses were based
on DSM-IV criteria. After the initial assessment, parents were invited
to the following session where the measures were applied. Children
with comorbid mental retardation, psychotic disorder and pervasive
developmental disorder were not included in the study. Boarding
children were also excluded. None of the children was on psychotropic
medication at the time of evaluation. Informed consent was obtained
and none of the cases refused to participate. The study was conducted
by a qualified child psychiatrist (Dr O.S.).

Measures
Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). This
scale is a ten-item, clinician rated, semi-structured instrument
designed to rate the severity of obsessive and compulsive symptoms in
children, aged 6 to 17 years (Scahill et al., 1997). Information obtained
from the child and parent is rated by the interviewer as reflecting the
average course of symptoms in the prior week of the interview. Psycho-
metric properties of CY-BOCS are still under evaluation worldwide. A
Turkish version was used for the present study which had been found
to possess good psychometric properties (Erkal et al., 2002).
Clinical Global Impression (CGI) – Severity Subscale (Guy, 1976).
This is scored from 1 (no illness) to 7 (completely nonfunctional). The
interviewer determines the overall severity of the illness. In the pres-
ent study design, two ratings, one for the school and the other for the
home setting were made and compared. This instrument has been used
in numerous studies exploring Turkish populations.
Setting Specificity Questionnaire (SSQ). This brief questionnaire was
prepared by the research team and was based on the results obtained
on the CY-BOCS. The children and their parents were questioned
about the frequency of symptoms across home and school settings with
particular reference to the CY-BOCS results. The symptoms displayed
at the weekends were not taken into consideration in order to make a
reliable comparison between the settings throughout schooldays.

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Sabuncuoglu and Berkem: Childhood Obsessive–Compulsive Disorder

Basic demographic data were gathered by reviewing the clinical

records of the cases. SPSS 10.0 for Windows was used to analyse the
findings. Differences were taken as significant if p < 0.05.

Results
Of all the children enrolled in the study, 15 (57.7 percent) were diag-
nosed as pure OCD, whilst the rest of the sample were given comorbid
diagnoses (Table 1). The mean length of time spent at school each day
was 7.07 ± 1.26 hours, which did not include the time spent in trans-
portation. Thus, all children spent one half of their waking day at
school and the other half at home. The frequencies of obsessions and
compulsions are shown in Table 2. The mean obsession and compulsion
subscores on the CY-BOCS were found to be 10.73 ± 3.14 and 10.88 ±
3.17, respectively. Both scores summed for a total score of 21.61 ± 5.52.
Children did not differ on the CY-BOCS regarding their gender, diag-
nosis (pure versus comorbidity) and age group (7 to ≤ 12 years versus
> 12 to 17 years), (Mann–Whitney U test, all p > 0.05).
The mean CGI-severity scores, rated for home and school settings
were 4.42 ± 0.90 and 2.42 ± 1.13 respectively (Figure 1), indicating a
strong difference in the presentation of OCD between those settings
(t = 7.02, df = 50, p < 0.0001, with Levene’s test revealing equal vari-
ances F = 0.05, p > 0.05). Although both CGI-severity ratings correlated
significantly (r = 0.442, p < 0.05), no correlation existed between the
CY-BOCS and CGI-severity scores. Likewise CY-BOCS, we did not find
any gender, diagnosis (pure versus comorbid) and age effect (7 to ≤ 12
years versus > 12 to 17 years), on the CGI-severity subscale (Mann–
Whitney U test, all p>0.05).
The estimates on the Setting Specificity Questionnaire (SSQ) were
found to be 77.69 percent for home setting and 22.30 percent for the
school setting (Figure 2). No difference was found on SSQ results in
regard to gender, diagnosis (pure versus comorbidity) and age group (7
to ≤ 12 years versus > 12 to 17 years), (Mann–Whitney U test, all
p > 0.05).
When the upper and lower 20 percent of the Total score of CY-BOCS
were analysed regarding the CGI-severity ratings for the settings, the
home scores differed significantly (p = 0.02) but the school scores did
not, indicating that symptoms displayed at home predict overall OCD
manifestation.

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 School Psychology International (2006), Vol. 27(2)

Table 1 The frequencies of comorbid disorders based on DSM-IV

criteria
Frequency Valid percent

Pure OCD 15 57.7

OCD, Tic Disorder 2 7.7
OCD, ADHD 3 11.5
OCD, Depression 1 3.8
OCD, Impulse Control Disorder 2 7.7
OCD, Substance Abuse 1 3.8
OCD, Tic Disorder, ADHD 2 7.7
Total 26 100

Table 2 The frequencies of obsessions and compulsions on the

CY-BOCS
Frequency Valid percent

Compulsions
Washing/cleaning 15 24.2
Checking 12 19.4
Repeating 15 24.2
Rituals involving others 7 11.3
Ordering/arranging 2 3.2
Hoarding/saving 3 4.8
Magical 2 3.2
Miscellaneous 6 9.7
Total 62 100.0

Obsessions
Contamination 16 32.0
Aggressive 18 36.0
Sexual 4 8.0
Magical 4 8.0
Somatic 3 6.0
Religious 4 8.0
Miscellaneous 1 2.0
Total 50 100.0

Discussion
As the frequencies of obsessions and compulsions in the present study
were similar to those of studies reported before, we can derive conclu-
sions from the present sample which we assume to represent childhood
OCD in general. Also, the CY-BOCS scores were similar to the results
reported in previous studies exploring childhood OCD with the same
instrument. However, given that the present sample size was small,
sex and age effects should be explored in larger samples.

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Sabuncuoglu and Berkem: Childhood Obsessive–Compulsive Disorder

4.5
4.0
4.42
3.5
3.0
2.5
2.0
2.42
1.5
1.0
0.5
0.0
Home School

Figure 1 CGI-severity subscores as rated for school and home settings

for the waking day (p < 0.0001)

School 23%

Home 77%

Figure 2 Child and parent estimated distribution of obsessive–

compulsive symptoms across settings on the Setting Specificity
Questionnaire (SSQ)

Despite the fact that previous research on childhood OCD has

revealed significant correlations between CY-BOCS and CGI, lack of
correlation between these measures in this study could be explained by
the dichotomized approach used to rate CGI for home and school set-
tings separately, unlike previous studies which used a single global
assessment.

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 School Psychology International (2006), Vol. 27(2)

This study aimed to delineate the presentation of the childhood OCD

across school and home settings and found significant differences
between these two. This finding is consistent on both clinician ratings
and children reports. Besides that, comorbidity, sex and age of the child
do not affect this finding. It is of interest that a neuropsychiatrically
determined disorder displays different presentations across settings.
In fact, the most frequent compulsions, noted in several studies reflect
a home-based symptom determination. Some children, if not all, may
be distracted from their overwhelming obsessive–compulsive thoughts
by the stimulations of the school environment. Children may have
obsessions but they may resist acting out their compulsions in the
social setting because of the anticipated shame. Secretiveness may
heighten in the classroom because of peer pressure. Eventually, the
social construct may facilitate response prevention which finally leads
to extinction of the obsessions. Therefore, longitudinal studies are
needed to test the efficacy of this suggestion.
Interpersonal factors that might trigger OCD symptoms within the
family should be explored. Early parental preoccupations and behav-
iours surrounding the birth of a family member, which was implicated
in the possible evolutionary origins of OCD, may provide insight
regarding the presentation difference phenomenon (Leckman et al.,
1999). Thus, separation from the setting where anxiety originates may
bring relief and lead to better outcome.
In a study of children with Tourette’s syndrome, it was found that
although obsessive–compulsive behaviour was prevalent among the
population, the presence of OCD did not lead to academic difficulties
(Abwender et al., 1996). This finding may also relate to the significant
discrepancy we have showed in our study, such that if the children are
less likely to display OCD symptoms at school, that eventually means
better academic performance. Similarly, the benefits of non-specific
milieu therapy which was reported to lead to recovery in adolescent
OCD patients (Apter et al., 1984; Apter and Tyano, 1988) might be
related to the phenomenon we present here. However, no further
attention has been paid to that approach and possible links to the
presentation difference phenomenon remains lacking. In a chart
review of 79 children and adolescents with severe OCD across a period
of 7.9 years, OCD was described as an illness with varied clinical
manifestations (Rettew et al., 1992). As the present study makes clear,
in schoolchildren setting is an important determinant of the manifest
symptoms. On the whole, our study is in agreement with previous
observations (McGough et al., 1993; Rapoport et al., 1994) regarding
the control of symptoms in public. Furthermore, as described by them-
selves, children with OCD report an overall decrease in the symptoms
experienced in the school setting, rather than controlling the compul-

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Sabuncuoglu and Berkem: Childhood Obsessive–Compulsive Disorder

sions in response to obsessions. As mentioned above, this may be an

outcome of response prevention which eventually leads to the extinc-
tion of obsessions.
One study on the functional impairment of children and adolescents
with OCD did not report any divergence at home and school presenta-
tions of the disorder (Piacentini et al., 2003); however, a recent
replication and extension study has noted that in childhood OCD, most
significant impairments occur at home (Valderhaug and Ivarsson,
2005). While that addresses secondary problems caused by OCD, it
may be accepted as an indirect evidence of OCD symptoms predomi-
nantly expressed at home.
Given the present findings, we should rethink what is already known
about the symptom manifestation in childhood OCD. It seems that the
school setting enables children to escape overwhelming OCD symp-
toms experienced at home. Thus, children with OCD, who do better at
school should be encouraged to spend more time in school activities.
Clinicians should pay particular attention to how their patients
with OCD manifest their symptoms. Diagnostic criteria required for
OCD diagnosis should not be so strict regarding the interference of
symptoms with school life. Assessment tools should be adjusted to
probe the issues addressed in this study.
In sum, the results of the present study are consistent with the pre-
vious observations (McGough et al., 1993; Rapoport et al., 1994) and
notably, one recent study reporting that children with OCD have most
severe functional impairments at home (Valderhaug and Ivarsson,
2005). As far as we are aware, this is the first study focusing precisely
on the presentation of childhood OCD across home and school settings.
We emphasize the importance of school setting as a starting point for
therapeutic interventions. Research directions vary with possible
implications for diagnosis, management and treatment. Further stud-
ies in larger samples are needed to delineate the characteristics and
possible benefits of this phenomenon.

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