Obsessive-Compulsive Disorder

About OCD

OCD is a type of anxiety disorder. Kids with OCD become preoccupied with whether something could be harmful, dangerous, wrong, or dirty — or with thoughts about bad stuff that might happen.

With OCD, upsetting or scary thoughts or images, called obsessions, pop into a person's mind and are hard to shake. Kids with OCD also might worry about things not being "in order" or "just right." They may worry about losing things, sometimes feeling the need to collect these items, even though they might seem useless to other people.

Someone with OCD feels strong urges to do certain things repeatedly — called rituals or compulsions — in order to banish the scary thoughts, ward off something dreaded, or make extra sure that things are safe, clean, or right.

Kids might have a difficult time explaining why they do their rituals, saying "just because." But in general, by doing rituals, kids with OCD are trying to relieve anxiety. They may want to feel absolutely certain that something bad won't happen or they may simply want something to feel "just right."

Think of OCD as an "overactive alarm system." The rise in anxiety or worry is so strong that a child feels like he or she must perform the task or dwell on the thought, over and over again, to the point where it interferes with everyday life.

Most kids with OCD realize that they really don't have to keep repeating the behaviors. But the anxiety can be so great that they feel that repetition is "required" to neutralize the uncomfortable feeling. And often the behavior does decrease the anxiety — but only temporarily. In the long run, the rituals may worsen OCD severity and prompt the obsessions to return.

Causes

Doctors and scientists don't know exactly what causes OCD, although recent research has led to a better understanding of it and its potential causes. Experts believe OCD is related to levels of a normal chemical in the brain called serotonin (known as a neurotransmitter).

When the flow of serotonin is blocked, the brain's "alarm system" overreacts and misinterprets information. "False alarms" mistakenly trigger danger messages. Instead of the brain filtering out these unnecessary thoughts, the mind dwells on them — and the person experiences unrealistic fear and doubt.

Also, imaging studies of the brain have shown that people with OCD have different patterns of brain activity than people without OCD.

Evidence is strong that OCD tends to run in families. Many people with OCD have one or more family members who also have it or other anxiety disorders influenced by the brain's serotonin levels. Because of this, scientists believe that the tendency (or predisposition) for someone to develop the neurotransmitter (serotonin) imbalance that causes OCD can be inherited.

Having the genetic tendency for OCD doesn't mean people will develop it; just that there's a stronger chance they might. Sometimes an illness or other stress-causing event may trigger the symptoms of OCD in someone who is genetically prone to develop it.

Common OCD Behaviors in Kids

OCD can make daily life difficult for the kids that it affects and their families. The behaviors often take up a great deal of time and energy, making it more difficult to complete tasks, such as homework or chores, or to enjoy life.

In addition to feeling frustrated or guilty for not being able to control their own thoughts or actions, kids with OCD also may suffer from low self-esteem or from shame or embarrassment about what they're thinking or feeling (since they often realize that their fears are unrealistic or that their rituals cannot really prevent their feared events).

They also may feel pressured because they don't have enough time to do everything. A child might become irritable because he or she feels compelled to stay awake late into the night or miss an activity or outing to complete the compulsive rituals. Kids might have difficulties with attention or concentration because of the intrusive thoughts.

Among kids and teens with OCD, the most common obsessions include:

• fear of dirt or germs
• fear of contamination
• a need for symmetry, order, and precision
• religious obsessions
• preoccupation with body wastes
• lucky and unlucky numbers
• sexual or aggressive thoughts
• fear of illness or harm coming to oneself or relatives
• preoccupation with household items
• intrusive sounds or words

These compulsions are the most common among kids and teens:

• grooming rituals, such as hand washing, showering, and teeth brushing
• repeating rituals, such as going in and out of doorways, needing to move through spaces in a special way, or rereading, erasing, and rewriting
• checking rituals, such as making sure that an appliance is off or a door is locked, and repeatedly checking homework
• rituals to undo contact with a "contaminated" person or object
• touching rituals
• rituals to prevent harming self or others
• ordering or arranging objects
• counting rituals
• hoarding and collecting things of no apparent value
• cleaning rituals related to the house or other items

Signs to Watch for

Recognizing OCD is often difficult because kids can become skilled at hiding the behaviors. It's not uncommon for a child to engage in ritualistic behavior for months, or even years, before parents know about it. Also, a child may not engage in the ritual at school, so parents might think that it's just a phase.

When a child with OCD tries to contain these thoughts or behaviors, this creates anxiety. Kids who feel embarrassed or as if they're "going crazy" may try to blend the OCD into the normal daily routine until they can't control it anymore.

It's common for kids to ask a parent to join in the ritualistic behavior: First the child has to do something and then the parent has to do something else. If a child says, "I didn't touch something with germs, did I?" the parent might have to respond, "No, you're OK," and the ritual will begin again for a certain number of times. Initially, the parent might not notice what is happening.

Tantrums, overt signs of worry, and difficult behaviors are common when parents fail to participate in their child's rituals. It is often this behavior, as much as the OCD itself, that brings families into treatment.

Parents can look for these possible signs of OCD:

• raw, chapped hands from constant washing
• unusually high rate of soap or paper towel usage
• high, unexplained utility bills
• a sudden drop in test grades
• unproductive hours spent doing homework
• holes erased through test papers and homework
• requests for family members to repeat strange phrases or keep answering the same question
• a persistent fear of illness
• a dramatic increase in laundry
• an exceptionally long amount of time spent getting ready for bed
• a continual fear that something terrible will happen to someone
• constant checks of the health of family members
• reluctance to leave the house at the same time as other family members

Environmental and stress factors can trigger the onset of OCD. These can include ordinary developmental transitions (such as starting school) as well as significant losses or changes (such as the death of a loved one or moving).

Diagnosing OCD

An estimated 1%-3% of children in the United States have OCD, which means that it's more common than many other childhood disorders or illnesses. But it often remains undiagnosed. Kids might keep the symptoms hidden from their families, friends, and teachers because they're embarrassed.

Even when the symptoms are present, a parent or health care provider might not recognize that they are part of a mental health disorder and may attribute them to the child's quirkiness or even bad behavior.

OCD is defined as a pattern of obsessive thinking and rituals that takes up more than an hour each day, causes distress, or interferes with daily activities. OCD in kids is usually diagnosed between the ages of 7 and 12. Since these are the years when kids naturally feel concerned about fitting in with their friends, the discomfort and stress brought on by OCD can make them feel scared, out of control, and alone.

It's important to understand that the obsessive-compulsive behavior is not something that a child can stop by trying harder. OCD is a disorder, just like any physical disorder such as diabetes or asthma, and is not something kids can control or have caused themselves. It's also not something that parents have caused, although life events may at times worsen or trigger the onset of OCD in kids who are prone to develop it.

If your child shows signs of OCD, talk to your doctor. In screening for OCD, the doctor or a mental health professional will ask about your child about obsessions and compulsions in language that kids will understand, such as:

• Do you have worries, thoughts, images, feelings, or ideas that bother you?
• Do you have to check things over and over again?
• Do you have to wash your hands a lot, more than most kids?
• Do you count to a certain number or do things a certain number of times?
• Do you collect things that others might throw away (like hair or fingernail clippings)?
• Do things have to be "just so"?
• Are there things you have to do before you go to bed?

Because it might be normal for a child who doesn't have OCD to answer yes to any of these questions, the doctor also will ask about how often and how severe the behaviors are, about your family's history of OCD, Tourette syndrome, and other motor or vocal tic disorders or other problems that sometimes occur with OCD.

More than a third of people with Tourette syndrome also have OCD (but only a small percentage of kids with OCD also have Tourette syndrome).

Other disorders that often occur with OCD include other anxiety disorders, depression, disruptive behavior disorders, attention deficit hyperactivity disorder (ADHD), learning disorders, and trichotillomania (compulsive hair pulling).

PANDAS

In rare cases, OCD symptoms or tics that come on very suddenly may be associated with a recent group A streptococcus infection (strep throat or, less commonly, scarlet fever). This phenomenon is known as PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections).

No one knows for sure why PANDAS occurs. One theory is that strep infections trigger an antibody response in some kids that causes changes in the basal ganglia, a part of the brain that has been implicated in OCD. Other infections (such as influenza, mycoplasma, or Lyme disease) have been shown to trigger the symptoms as well.

Of course, a child who has had strep throat doesn't automatically develop PANDAS. Almost all school-age kids have strep throat at some point, and the vast majority recover with no complications. Similarly, most kids who have OCD or tics do not have PANDAS. There is currently some controversy among researchers over whether the PANDAS theory is valid. Scientists are studying this to better understand the connection between infections and OCD.

Treating OCD

The most successful treatments for kids with OCD are behavioral therapy and medication. Behavioral therapy, also known as cognitive-behavioral psychotherapy (CBT), helps kids learn to change thoughts and feelings by first changing behavior. It involves gradually exposing kids to their fears, with the agreement that they will not perform rituals, to help them recognize that their anxiety will eventually decrease and that no disastrous outcome will occur.

For example, kids who are afraid of dirt might be exposed to something dirty, starting with something mildly bothersome and ending with something that might be really dirty. For exposure to be successful, it must be combined with response prevention, in which the child's rituals or avoidance behaviors are blocked. For example, a child who fears dirt must not only stay in contact with the dirty object, but also must not be allowed to wash repeatedly.

Some treatment plans involve having the child "bossing back" the OCD, giving it a nasty nickname, and visualizing it as something he or she can control. Over time, the anxiety provoked by dirt and the urge to perform washing rituals gradually disappear. The child also gains confidence that he or she can "fight" OCD.

OCD can sometimes worsen if it's not treated in a consistent, logical, and supportive manner. So it's important to find a therapist who has training and experience in treating OCD. Just talking about the rituals and fears have not been shown to help OCD, and may actually make it worse by reinforcing the fears and prompting extra rituals. Family support and cooperation also go a long way toward helping a child cope with OCD.

Many kids can do well with behavioral therapy alone while others will need a combination of behavioral therapy and medication. Therapy can help your child and family learn strategies to manage the ebb and flow of OCD symptoms, while medication, such as selective serotonin reuptake inhibitors (SSRIs), often can reduce the impulse to perform rituals.

Helping Kids With OCD

Remember, OCD is never a child's fault. Once a child is in treatment, it's important for parents to participate, to learn more about OCD, and to modify expectations and be supportive.

Kids with OCD get better at different rates, so try to avoid any day-to-day comparisons and recognize and praise any small improvements. Keep in mind that it's the OCD that is causing the problem, not the child. The more that personal criticism can be avoided, the better.

It can be helpful to keep family routines as normal as possible, and for all family members to learn strategies to help the child with OCD. It's also important to not let OCD be the "boss" of the house and regular family activities. Giving in to OCD worries does not make them go away.

Reviewed by: Elana Pearl Ben-Joseph, MD
Date reviewed: February 2012