Obsessive compulsive disorder can occur in both
children and adults. It is characterized by obsessions (repeated
thoughts or images which cause distress) and compulsions (repetitive
behaviors or rituals) These symptoms are often associated with
significant anxiety and depression. The affected individual often fears
that he is "'going crazy."
Obsessions may often involve thoughts which seem
unacceptable to the individual, so that he or she feels ashamed. Because
of this, many people keep their thoughts a secret and suffer silently.
In the past decade, there have been advances in the behavioral and
pharmacological treatment of Obsessive Compulsive Disorder.
Diagnosis and Treatment of OCD in Children and Adolescents
Obsessive-Compulsive Disorder in Adults
Books for Children and Adolescents with OCD
Our Presentations on OCD in Children
Separation Anxiety Disorder See our article on this topic
Disorder in Children and Adolescents
Carol E. Watkins, M.D.
At one time, Obsessive Compulsive Disorder (OCD)
was believed to be fairly rare. When it was diagnosed, it seemed
resistant to treatment. In the past decade, we have learned that it is
much more prevalent. Community surveys of adolescents have suggested
that at any given time, 1% to over 3% are experiencing symptoms of OCD.
Children as young as 5 or 6 can show full-blown OCD. Between 30% and 50
% of adults with OCD reported that their symptoms started during or
before mid-adolescence. Fortunately, there are now more effective
treatments for OCD. In many ways the symptoms and treatments of OCD in
both children and adults follow the same general principles. However,
children differ from adults cognitively, developmentally and
physiologically. Because of this, we modify techniques based on the
particular stage of childhood or adolescence.
Symptoms and Features of OCD
In order to meet DSM-4 criteria for OCD, the
individual must have either obsessions or compulsions. In actuality,
most children and adolescents have both.
The Diagnostic and Statistical Manual of the
American Psychiatric Association (DSM-4) defines obsessions as follows:
1. Recurrent and persistent thoughts,
impulses or images that are experienced, at some time during the
disturbance, as intrusive and inappropriate and that cause marked
anxiety or distress
2. The thoughts, impulses, or images are
not simply excessive worries about real-life problems.
3. The person attempts to ignore or
suppress such thoughts, impulses, or images, or to neutralize them
with some other thought or action.
4. The person recognizes that the
obsessional thoughts, impulses, or images are a product of his or
her own mind (not imposed from without as in thought insertion)
The DSM-4 defines compulsions as:
1. Repetitive behaviors (e.g. hand
washing, ordering, checking) or mental acts (e.g. praying, counting,
repeating words silently) that the person feels driven to perform in
response to an obsession, or according to rules that must be applied
2. The behaviors or mental acts are aimed
at preventing or reducing distress or preventing some dreaded event
or situation; however, these behaviors or mental acts either are not
connected in a realistic way with what they are designed to
neutralize or prevent or are clearly excessive.
The DSM-4 also requires:
1. The obsessions or compulsions cause
marked distress, are time consuming (take more than 1 hour per day),
or significantly interfere with the person's normal routine,
occupational (or academic) functioning, or usual social activities.
2. At some point during the course of the
disorder, the person has recognized that the obsessions or
compulsions are excessive or unreasonable. Note: This does not apply
When a clinician is evaluating a child or
adolescent for possible OCD, it is important to do a thorough work up.
The clinician should meet with the child and ask specific questions
about obsessions and compulsions. He or she should also meet with
parents or other primary caregivers. Information from school and other
outside sources is also useful. If there are obsessions or rituals that
occur only at school, it is important to know about them, so that they
can be addressed too. The parents and usually the child may also fill
out checklists such as the YBOCS (Yale-Brown Obsessive Compulsive Scale)
These help to determine the baseline number and severity of the
symptoms. Since OCD can be associated with other disorders, the
clinician should look other childhood psychiatric disorders.
Most individuals with OCD, even young ones, are at
least intermittently aware that their symptoms do not make logical
sense. However, young children are less capable of abstract thought, so
their degree of insight may not be as good.
There have been several theories about the cause
of OCD. These include psychodynamic, learning theories, and neuro-biological.
When we discuss cause, it is important to make it clear that we are
looking at Obsessive Compulsive Disorder, not an obsessive,
perfectionistic personality style. An obsessive-compulsive personality
disorder is different from true Obsessive-Compulsive Disorder. There may
be some overlap or it may have a different origin.
Psychodynamic: Freud classified Obsessive
Compulsive Disorder as a psychoneurosis. The roots of the illness lay in
a disturbance in the sexual life or development of the child. Freud did
recognize that one's heredity and innate constitution contributed to the
development of the disorder. In Freud's theory of infantile sexuality,
the child goes through the stages of oral, anal and oedipal sexual
interest. If the child does not successfully progress through each
phase, he may develop later difficulties. During early childhood,
sometimes during or just before the oedipal phase, there might be a
conflict between the ego (the mediating and observing entity) and the id
(the source of sexual and destructive energy). The ego solves the
conflict by setting up a way of reducing the effect of the id. In some
cases, the solution is an unstable one. Part of the unstable compromise
might be regression to the earlier anal level of development. Such an
individual might have a tendency to hoard and a horror of throwing
things away. Other obsessive symptoms such as checking might be seen as
a way of dealing with the unwanted intrusion of hostile oedipal wishes.
(Such as a boy wishing his father dead so he could marry his mother.) If
one needed to repeatedly check faucets, it might be a defense against a
childhood wish to flood the house and thus kill the father. The symptoms
may start to express themselves years later when something happens to
weaken the ego and its shakier defenses.
It is possible that these psychodynamic
formulations are more relevant to individuals with obsessive or
compulsive personality traits rather than to individuals with true OCD.
Biological: Most recent research studies point
toward a biological basis for OCD. However, there may be subtypes of
OCD. Different subtypes may have distinct biological mechanisms. As
research continues, the understanding of the neurological and related
biochemical mechanisms will improve. PET Scans (a kind of brain scan
that shows levels of brain activity in specific areas.) have shown
abnormalities in the sub-orbital cortex (the underside of the front part
of the brain) and the basal ganglia. A striking abnormality was
increased activity in the sub-orbital cortex. When patients were
successfully treated, whether with psychotherapy or medication, the
brain scan studies resembled those individuals without OCD. Serotonin
seems to be involved in mediating the interaction between these two
parts of the brain.
Some cases of OCD may be associated with
Tourette's Disorder. Tourette's is characterized by multiple tics.
(involuntary rapid movement or vocalization) Individuals with Tourette's
may also have OCD symptoms, and Attention Deficit Disorder. Tourette's
is often inherited. Relatives of individuals with Tourette's may have
OCD without the tics. Finally, recent research has suggested that some
cases of OCD may be related to the bacteria, B-hemolytic streptococcus.
This syndrome is referred to as PANDAs. Antibodies may attack segments
of the brain to produce an acute onset of OCD symptoms. Similar
antibodies may cause rheumatic heart disease. More research is needed in
this area. However, if the OCD starts suddenly, around the same time as
an upper respiratory illness, one might consider a throat swab to check
for the presence of B-hemolytic streptococcus infection. If the bacteria
are present, further tests, treatment with an antibiotic and a referral
to a specialized center might be considered.
Tourette's Disorder is more likely to be present
in boys and in children who develop OCD at a younger age. It is
important to identify this disorder because treatment may need to be
modified. Children and adolescents with OCD are more likely to have
Attention Deficit Disorder, learning disorders oppositional behavior,
separation anxiety disorder and other anxiety disorders. Some of the
anxiety disorders have similarities to OCD and are called
obsessive-compulsive spectrum disorders. These include tricotillomania,
(compulsive hair pulling and twirling, ) body dysmorphic disorder (the
obsession that part of one's body is unattractive or misshapen) and
habit disorders such as nail biting and scab picking. The exact
relationship between these two spectrum disorders and true OCD is not
yet entirely clear.
Consequences of OCD
If not treated, OCD tends to be a long-term
disorder. Some individuals experience waxing and waning symptoms over
the years. Others experience progressive worsening of their OCD until
they are housebound and spend much of their days involved in obsessions
and rituals. Chronic anxiety disorders may lead to depression. If a
child spends a great deal of time obsessing or engaging in mental
rituals, he or she may have trouble focusing on the school lessons.
Individuals who need to repeatedly erase and rewrite assignments may
need to spend hours of time of homework and lose time for friends and
family. This same individual may not be able to finish projects because
the work is never "just right." Some children and teens may become
oppositional if others attempt to interrupt their rituals. For the large
number of individuals who manage to hide their symptoms, the cost may
simply be years of anxiety and low self-esteem.
Children and Adolescents are Different from Adults
The DSM-4 criteria for children and adults differ
for the criterion on insight. An adult generally is at least
intermittently aware that the obsessions or compulsions are unrealistic.
Most of the time, this is also true for children and adolescents.
However some children, particularly young ones, may not have the
cognitive capacity to understand the nature of the obsessions or
compulsions. Oppositional children or adolescents may not want to admit
that there is something awry with their behavior. In that case, a
therapeutic alliance with a clinician may enable him or her to discuss
his or her real feelings about the symptoms. Family issues are different
for children. The child’s cognitive development necessitates some
changes in the psychotherapeutic approach. If medications are used, the
physician must consider the child’s smaller size and different
In this article, we will focus on medication and
cognitive-behavioral psychotherapy. There are other psychodynamic, play
therapy and family therapy approaches to the treatment of OCD.
Once a child has been diagnosed with OCD, we need
to decide which treatment or treatments to use first. Many clinicians
prefer to start off with cognitive-behavioral psychotherapy. If there is
no response or only a partial response, medication may then be added.
There circumstances in which it is appropriate to start medication and
psychotherapy simultaneously or even to start with medication alone.
Moderate to severe OCD may merit starting with a combined approach. If a
child or adolescent is extremely resistant to the idea of psychotherapy,
one might consider starting with medication alone.
It would be difficult to discuss this topic
without giving a great deal of credit to John March MD and his
collaborators. They have developed, tested, and disseminated specific
information that includes a detailed protocol for treatment of childhood
Near the beginning of this type of therapy, the
child and family are educated about the biological basis of OCD. Even
young children can gain some understanding of this concept if it is
presented in an age-appropriate manner. For young children, I often draw
an outline of the brain and let them color round and round to signify
the repetitive thoughts and actions. Older children and adolescents may
appreciate pictures of brain imaging studies. I have used the pictures
in the introduction section of the book, Brain Lock by Jeffrey Schwartz,
MD. These pictures vividly show the differences in brain activity
between affected and unaffected individuals.
When the child and family realize the biological
basis of the disorder, they find it easier to externalize the symptoms.
The symptoms are the fault of the disease, not the individual or family.
Children continue to need more concrete models and concepts throughout
the therapy. Often one may help them conceptualize the OCD or OCD
symptoms as an unpleasant or silly creature. The child may also want to
give this creature a name. In the illustrated children’s book, Blink,
Blink, Clop, Clop, Why Do We Do Things We Can’t Stop? The OCD is named "OC
Flea", and is drawn as an unattractive, silly but non-threatening
creature. Subsequent therapy helps the child shrink, squash, boss or
drive away the OCD.
As the therapy progresses, the child should begin
to expose himself to the anxiety-provoking object or situation and then
try to avoid performing the usual compulsion. This is called exposure
and response prevention. It may have to be done gradually because it can
cause the child to experience significant anxiety. The child himself
should have an important role in determining how quickly he wants to
move through these steps. The parents can help with this too by reducing
and then eliminating reassurances when a child asks obsessive questions.
At the same time, they should be supportive and avoid blaming the child
if he is unable to avoid performing some of the compulsions.
The child may benefit from learning relaxation
techniques and learning mental self-monitoring. Other specific
techniques may help individual children tolerate the anxiety engendered
by the exposure and response prevention.
When the symptoms are eliminated or at least
reduced to a tolerable level, the therapist should talk to the child and
parents about the future. Symptoms may start to come back at a later
date. They should review the symptoms and discuss how to deal with them.
Some individuals come in for intermittent refresher sessions.
Recent advances in medication have added to our
treatment options. In the past few years there have been more studies
testing these medications specifically on children. In general, children
who need medication respond to the same medications used for adults with
OCD. The FDA has approved some of these medications for use in children
with OCD. However, a physician may, after discussion with the family,
elect to use a medication that technically is only approved for adults.
Families should be aware that in the fall of 2004, the FDA issued the
advisory on the use of antidepressants in children and adolescents.
- Clomipramine, (Anafranil) ages 10 and up
- Fluvoxamine, (Luvox) ages 8 and up
- Sertraline, (Zoloft) ages 6 and up.
- Fluoxetine, (Prozac) approved for adults
and for children ages 7 and up for depression and OCD
- Paroxetine (brand name Paxil) approved
The main medications used for OCD are Clomipramine
(brand name Anafranil) and the Selective Serotonin Reuptake Inhibitors.
There are several other medications that may be added if those
medications produce only a partial response.
Clomipramine is chemically similar to the older
tricyclic antidepressants. Its efficacy in OCD seems to be related to
its ability to decrease serotonin reuptake. It used to be the only
effective drug for OCD. At this point, it is usually not the first line
drug for children with OCD. This is because of several potential side
effects. It can be sedating. It can also cause dry mouth and eyes. It
has been associated with some changes in EKGs. (A measure of the heart
rate and the electrical conduction within the heart.) Because children
may be more sensitive to this cardiac effect, we usually monitor EKGs
and heart rate in children on Clomipramine. Despite this, when used
carefully, it has helped many children and adolescents with OCD.
There are now several SSRI medications. They
include Fluoxetine (brand name Prozac) Fluvoxamine (brand name Luvox)
Paroxetine (brand name Paxil) and Sertraline (brand name Zoloft). All
seem to be effective at reducing the symptoms of OCD, but different ones
may be best for individual patients. Fluoxetine has the advantage of
being available in liquid form. Using the liquid, one can start at very
small doses and titrate the dose gradually. Common side effects include
headache, GI complaints, tremor, agitation, drowsiness and insomnia.
These medications may affect how other drugs are broken down in the
liver. One must use caution when mixing medications. If a child taking
an SSRI, it is a good idea to consult one’s physician or pharmacist
before taking other prescription or even non-prescription medications.
Many children take a long time to achieve a good response to medication.
10 to 12 weeks is not uncommon. Some children will respond to one
medication but not to another.
Dealing with Recurrences
Education about OCD often an early part of the
therapy. Both parents and child are included. It is important for them
to continue the education process. A good understanding of the disorder
can help the child and family feel a greater sense of mastery and
The process of education should extend on after
the end of the therapy. It can occur through reading age-appropriate
books, attending support groups or having group therapy with peers. I
have listed some recommended books and support groups at the end of the
article. Secrecy and shame are common in individuals with OCD. Education
and the support of others can help the individual keep the disorder in
Children and families should be aware that OCD can
be chronic and that symptoms may return months or years later. Some
children will schedule "check up" sessions every six months or each
year. If symptoms reoccur, they may return to therapy for a shortened
version of their previous treatment.
Suggested readings and Internet Links
Brain Lock: Free Yourself from
Obsessive-Compulsive Behavior by Jeffrey M. Schwartz 1996, Regan Books.
This book is primarily aimed at adults. However, I have found it useful
for adolescents and for relatives of the child or adolescent with OCD.
Dr. Schwartz discusses both the causes and symptoms of OCD. He then
suggests a four-step self-help approach to help the individual deal with
the symptoms of OCD. For those who do not want to read the entire book,
he provides a summary of the basics of the four steps near the end of
the book. Some individuals may be able to use the book to deal with the
OCD by themselves. I prefer to use it with patients as an adjunct to
therapy and as a reminder between sessions.
Blink, Blink, Clop, Clop: Why Do We Do Things We
Can't Stop? by Moritz and Jablonsky, ChildsWork, ChildsPlay (1998) This
illustrated book explains OCD to elementary-aged children. It uses the
metaphor of farm animals who are tormented by "O.C.Flea." It can be a
useful story early on in the child's therapy. This book is probably best
read with or to a child. Some of the concepts and vocabulary are more
advanced and should be explained.
OCD in Children and Adolescents: A
Cognitive-Behavioral Manual by John March and Karen Mulle1998, The
Guilford Press. This book is fairly technical and is aimed at
psychiatrists and other mental health professionals. This book contains
the excellent cognitive-behavioral protocol that Dr. March has been
using successfully with children and adolescents with OCD. The book also
discusses in more depth special considerations in treating OCD as it
occurs in children.
AACAP, (1998) Practice Parameters for the
Assessment and Treatment of Children and Adolescents with
Obsessive-Compulsive Disorder, Journal of the American Academy of Child
& Adolescent Psychiatry, 37:10;27s-45s.
American Psychiatric Association (1994) Diagnostic
and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)
Washington, D.C. American Psychiatric Association.
Obsessive Compulsive Disorder in Adults
Glenn Brynes, PhD, MD
Description of symptoms
"Imagine you are getting up in the morning. You know you will need to go
to the bathroom, but the thought of accidentally touching the doorknob
is frightening. There may be dangerous bacteria on it. Of course you
cleaned the entire bathroom yesterday, including the usual series of
disinfectant spraying, washing and rinsing. As usual it took a couple of
hours to do it the right way. Even then you weren't sure whether you had
missed an area, so you had to re-wash the floor. Naturally the doorknob
was sprayed and rubbed three times with a bactericidal spray. Now the
thought that you could have missed a spot on the doorknob makes you very
nervous. Maybe you should have cleaned it another time? Carefully you
put on your laundered slippers and think to yourself repeatedly, "The
Lord will protect me from all germs; I will fear no evil", and cross the
floor to the bathroom, careful to do it in exactly 10 steps. On some
days you spend so much of your time checking, cleaning and arranging
things, there is little time left for other matters."
This description might give you some sense of the tormented and anxious
world that people with Obsessive Compulsive Disorder (OCD) live in. It
is a world filled with dangers from outside and from within. Often
elaborate rituals and thoughts are used to ward off feared events, but
no amount of mental or physical activity seems adequate, so doubt and
anxiety are often present.
Obsessions are thoughts or images that seem to intrude into a person's
mind. While he generally knows they are his own thoughts, he can't
control them, and finds them very disturbing. They may take the form of
fears of something terrible happening to himself, his friends or family,
often as a result of his own actions or neglect.
Compulsions are behaviors that usually are repetitive and stereotyped.
They may take the form of actions or thoughts. The compulsive behaviors
are intended to reduce the anxiety engendered by obsessions. People who
do not have OCD may perform behaviors in a ritualistic way, repeating,
checking, or washing things out of habit or concern. Generally this is
done without much if any worry. What distinguishes OCD as a psychiatric
disorder is that the experience of obsessions, and the performance of
rituals, reaches such an intensity or frequency that it causes
significant psychological distress and interferes in a significant way
with psychosocial functioning. The guideline of at least one hour spent
on symptoms per day (American Psychiatric Association 1994; Goodman et
al. 1989b) is often used as a measure of "significant interference."
However, among patients who try to avoid situations that bring on
anxiety and compulsions, the actual symptoms may not consume an hour.
Yet the quantity of "time lost" from having to avoid objects or
situations would clearly constitute interfering with functioning.
Consider, for instance, a welfare mother who throws out more than $100
of groceries a week because of contamination fears. Although this
behavior has a major effect on her functioning, it might not consume one
hour per day.
Patients with OCD describe their experience as having thoughts
(obsessions) that they associate with some danger. The sufferer
generally recognizes that it is his own thought, rather than something
imposed by someone else (as in some paranoid schizophrenic patients).
However the disturbing thought cannot be dismissed, and simply nags at
him. Something must then be done to relieve the danger and mitigate the
fear. This leads to actions and thoughts that are intended to neutralize
the danger. These are the compulsions. Because these behaviors seem to
give the otherwise "helplessly anxious" person something to combat the
danger, they are temporarily reassuring. However, since the "danger" is
typically irrational or imaginary, it simply returns, thereby triggering
another cycle of the briefly reassuring compulsions. From the standpoint
of classic conditioning, this pattern of painful obsession followed by
temporarily reassuring compulsion eventually produces an intensely
ingrained habit. It is rare to see obsessions without compulsions.
The two most common obsessions are fears of contamination and fear of
harming oneself or others. The two most common compulsions are checking
and cleaning (Foa and Kozak 1995).
OCD Can Mimic Other Disorders
An OCD sufferer with an intense fear of contamination might avoid the
object of his fear by staying home, and thus become housebound as in
agoraphobia. The distinction becomes apparent when the reason for
staying home is investigated.
Obsessive Compulsive Disorder may manifest with fears of contracting
severe illnesses, such as cancer, venereal diseases or AIDS. These
somatic obsessions may resemble hypochondria. Despite the similarities,
the OCD patient will often have a typical history of various obsessions
and compulsive symptoms that are not primarily somatic (e.g. fears of
hitting someone, compulsions to count or check).
OCD can result in depression as well as avoidant behavior that resembles
specific or social phobias. The degree of anxiety experienced in
connection with the obsessions may be so pervasive that it can resemble
generalized anxiety disorder.
Genetics of OCD
The prevalence of OCD in the United States is estimated to be 2-3%. Thus
5-7 million Americans have this illness. Studies of OCD patients and
their families have established a 10% prevalence of OCD in first degree
relatives (an additional 8% have a subclinical degree of OCD symptoms).
The genetic connection seems to be higher if the onset of OCD is before
age 14. In studies of twins, there is a 63% concordance rate for OCD in
Treatment of OCD
Prior to studies in the 1980's, the usual view of OCD was that it was a
relatively rare disorder with a poor prognosis. However, in addition to
it being now recognized to be much more common (2-3% prevalence rate),
it is generally seen to be treatable, with some 60%–80% of patients
showing at least some response to treatment.
It is generally thought that the serotonin system in the brain is
involved in the pathology of OCD, since the pharmacological agents that
have been shown to be effective in the treatment of this disorder
generally increase the availability of this neurotransmitter. These
include the serotonin re-uptake inhibitors: clomipramine, fluoxetine,
sertraline, paroxetine, fluvoxamine, and citalopram.
Behavioral therapy—specifically ERP [Exposure and Response
Prevention]—has been successfully used for the treatment of OCD. The
idea behind ERP is that compulsions provide only a temporary reduction
of the anxiety produced by obsessions. Furthermore, the only way to
experience more permanent relief is to habituate (grow tolerant of…"used
to") the anxiety caused by the obsession without performing the
compulsion. Habituation is the key factor, and clinicians proceed by
first identifying triggers for and situations that bring on obsessional
thoughts and compulsive behaviors and then developing a graduated
hierarchy of anxiety based on the patient's report. The patient
"challenges" him- or herself with the least anxiety-provoking items
first and then moves up the hierarchy. In addition to exposure, the
patient is instructed to refrain from carrying out the associated
Heidi was afraid of germs and dirt. She felt very uncomfortable whenever
she had to go into a bathroom. She carried tissues with which to open
the bathroom door, and had to wash her hands several times before
leaving the bathroom. The door was then opened with a paper towel. If
she accidentally touched the door, she had to wash all over again.
For her ERP treatment, Heidi was told to spent 10 minutes sitting on a
chair in her bathroom without washing her hands. This was to be repeated
each day for a week. Initially she felt very uncomfortable, and greatly
wished to clean her hands. She found herself thinking of the dirt and
"germs" that she felt must be everywhere in the bathroom. However with
much effort she was able to tolerate this. Once she had 'mastered' this
she was told to increase the time from 10 to 20 minutes. She was still
uncomfortable, but was a bit surprised that spending twice as long
didn't mean being twice as uncomfortable. Indeed after about 10 minutes,
she felt somewhat relieved that nothing terrible had occurred. Further
extending the time to 30 minutes simply led to her feeling that nothing
was going to happen if she spent more time not washing. Once Heidi had
mastered this, she was told to touch the inside of the sink, and not
wash her hands for 10 minutes. Since she regarded the sink as one of the
moderately dirty places in the bathroom, this presented a new challenge
for her. As she mastered one level of discomfort, she was moved on to
the next more challenging level, until she finally was able to use the
bathroom without intolerable anxiety and without her usual rituals.
An added benefit of behavioral treatment is its long-term efficacy.
Unlike pharmacotherapy, whose beneficial effects do not last in the
great majority of patients after medication is withdrawn, behavioral
therapy has shown continued efficacy in follow-up studies ranging from 1
to 6 years, although booster sessions may be required.
Obsessive Compulsive Disorder is more common than generally believed 20
years ago. It appears to be largely a neuropsychiatric condition, rather
than a product of overly strict upbringing (as was once believed).
Although OCD can have a paralyzing impact if not properly diagnosed and
treated, there are fortunately behavioral and pharmacological approaches
available that can help many of the sufferers from this potentially
Our practice, located in Lutherville and Monkton,
Maryland, has psychiatrists and therapists who are experienced at
treating obsessive compulsive disorder. We are experienced in providing
both medications and cognitive-behavioral psychotherapy. We see patients
from Baltimore County, Carroll County and Harford County. Because of our
Monkton office is close to the state border, we see a number of patients
from York County, Pennsylvania. For more information about our practice,
see our home page