Obsessive-Compulsive Disorder Basics

Children with obsessive-compulsive disorder (OCD) are plagued by unwanted and stressful thoughts and fears that they try to alleviate by performing compulsive rituals like counting or washing their hands. This guide explains how OCD impacts children, how it's diagnosed and the most effective treatments.

OCD: What Is It?

Obsessive-compulsive disorder (OCD) is an anxiety condition that plagues a person with unwanted thoughts, images or impulses—called obsessions—that are impossible to suppress, causing him great stress and worry. He develops repetitive, ritualized actions—compulsions—to alleviate the anxiety caused by these obsessions. These compulsions, which can be behaviors or mental acts like counting, are not connected in a realistic way with the threats they are designed to neutralize or prevent. Common obsessions include fear of contamination, fear of harm to himself or others, and fear that he might do something violent or terrible. Children with OCD may compulsively wash their hands, lock and relock doors a certain number of times, line up objects or touch parts of their bodies symmetrically in order to neutralize a fear and make themselves comfortable. They may also repeatedly ask questions and seek reassurance.

OCD: What to Look For

Young children experience OCD differently than adolescents and adults. The disorder can manifest as early as 5, but a child may lack the self-awareness to recognize that his thoughts and fears are exaggerated or unrealistic, and he may not be fully aware of why he is compelled to perform a ritual; he just knows that it gives him a “just right” feeling, at least momentarily. Later, what professionals call “magical thinking” emerges: Though he knows it is far-fetched, a child finds himself compelled, if he has scratched his left shoulder, to scratch his right shoulder, so mom will be less likely to die in a car accident, for instance. In any case, the response is highly structured and repetitive, making the child appear rigid and rule-bound and interfering with normal functioning. And while all children seek reassurance from adults, children and adolescents with OCD ask repeated questions about the future.

OCD obsessions fall in to a variety of categories: contamination (germs, waste, bodily fluids, chemicals, etc.), symmetry (lack of which could cause bad luck), fear of harm or responsibility for harm (the house will burn down, a parent will be hurt in an accident), aggressive (I might hurt the baby), among others. Since obsessions can be impulses as well as ideas or images, the compulsion in response to a dreaded impulse can be to avoid contact or problematic situations, or isolate oneself. Likewise, the rituals performed can be mental rather than physical, and go unrecognized by parents—and even the child.

OCD: Risk Factors

Kids with more negative temperaments and behavioral inhibition are more likely to develop obsessive-compulsive disorder, as are those with first-degree relatives who have OCD. Likelihood particularly increases with relatives who had child-onset OCD. Children who have experienced abuse or other stressful or traumatic events are also more at risk.

Some children experience a sudden onset of OCD symptoms associated with various infectious agents and a post-infectious autoimmune syndrome (also known as PANDAS or PANS).

OCD: Diagnosis

A clinician will make a diagnosis if your child has obsessions, compulsions, or both. Obsessions are unwanted thoughts, images or urges that cause marked anxiety and an effort on the child’s part to suppress or neutralize them by thoughts or actions. Compulsions are repetitive, rule-based efforts to alleviate the anxiety that are not connected in a realistic way with what they are designed to neutralize. The behavior must interfere significantly with a child’s normal activities. In addition to the basic diagnosis, a professional can also determine the severity of the case and track the effectiveness of treatment using a widely accepted rating scale called Y-BOCS, or the Yale-Brown Obsessive Compulsive Scale.

OCD: Treatment

Mild cases of OCD are often treated with cognitive behavior therapy alone, or medication alone; research shows them to be equally effective. But as symptoms intensify or impairment reaches the moderate to severe range, the best approach is the combination of CBT and medication.

Psychotherapeutic: OCD is best treated with cognitive behavior therapy, specifically a technique called exposure and response prevention. This technique introduces a child to the objects of his obsession in incremental doses in a controlled environment, in which he can experience his anxiety and distress without resorting to compulsions. Over time, the child will become habituated, the anxiety response will diminish, and the child will be able to give up the compulsion. The professional will work with your child to develop a “fear hierarchy,” and work on exposure from the easiest, least stressful trigger of OCD behavior up to the most dreaded. Much of the work and improvement is done at home, as the whole family is trained by the clinician to work on exposure tasks.

Many experts caution that traditional talk therapy does not help children with OCD, as talking about the disorder can increase anxiety about obsessions.

Pharmacological: More severe cases of OCD are often treated with a combination of CBT and medication, including SSRIs, or selective serotonin reuptake inhibitors. The medication reduces anxiety and allows the child to be more responsive to the exposure therapy. Once he has acquired skills to overcome the anxiety, medication can be decreased or discontinued.

Whether the treatment is behavioral or pharmacological or both, OCD patients will often return to their clinician in the years following their initial treatment for “booster sessions” to freshen up the skills they learned to control their anxiety levels.

OCD: Risk For Other Disorders

Depression is often diagnosed in those with OCD. Other disorders that frequently occur alongside OCD include eating disorders, panic disorder, and Tourette’s syndrome. On the other hand, because of the intense stress and anxiety produced by OCD, it is often mistakenly diagnosed as another disorder. A child with contamination obsessions, say, who cannot leave the classroom to “fix” his anxiety during school, may become so distracted that his condition is confused with attention-deficit hyperactivity disorder.