All kids have worries and doubts. But kids with obsessive-compulsive disorder (OCD) often can't stop worrying, no matter how much they want to. And those worries frequently compel them to behave in certain ways over and over again.
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 may also worry about things being out of "order" or not "just right." They may worry about losing "useless" items, sometimes feeling the need to collect these items.
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 or clean or right. Children may have a difficult time explaining a reason for their rituals and say they do them "just because." But in general, by doing a ritual, someone with OCD is trying to feel absolutely certain that something bad won't happen.
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 repeat the behaviors over and over again, 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 only worsen OCD severity and prompt the obsessions to return.
Doctors and scientists don't know exactly what causes OCD, although recent research has led to a better understanding of OCD and its potential causes. Experts believe OCD is related to levels of a normal chemical in the brain called serotonin. When the proper flow of serotonin is blocked, the brain's "alarm system" overreacts and misinterprets information. Danger messages are mistakenly triggered like "false alarms." Instead of the brain filtering out these unnecessary thoughts, the mind dwells on them — and the person experiences unrealistic fear and doubt.
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 have come to believe that the tendency (or predisposition) for someone to develop the serotonin imbalance that causes OCD can be inherited through a person's genes.
Having the genetic tendency for OCD doesn't mean people will develop OCD, but it means there is a stronger chance they might. An imbalance of serotonin levels can also result in other types of anxiety or depression.
An estimated 1% of children in the United States experience OCD, which is characterized by a pattern of rituals and obsessive thinking that generally lasts more than an hour each day, causes a child distress, or interferes with daily activities. It's more prevalent than many other childhood disorders or illnesses, but kids often keep the symptoms hidden from their families, friends, and teachers because they're embarrassed by them.
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 is 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.
Common OCD Behaviors in Kids
OCD can make daily life difficult for the kids that it affects and for 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 are not realistically going to 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, including hand washing, showering, and teeth brushing
- repeating rituals, including going in and out of doorways, needing to move through spaces in a special way, or rereading, erasing, and rewriting
- checking rituals to make 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
- cleaning rituals related to the house or other items
Signs and Symptoms of OCD
Recognizing OCD is often difficult because kids can become adept 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, which brings families into treatment.
Parents can look for the following 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).
If your child shows signs of OCD, talk to your doctor. In screening for OCD, a doctor or 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 your family's history of OCD, Tourette syndrome, and other motor or vocal tic disorders to determine whether your child has a genetic predisposition to OCD.
Tic disorders often resemble OCD: up to half of people with Tourette syndrome also have OCD (but only a small percentage of kids with OCD also have Tourette syndrome).
Other disorders that frequently occur with OCD include other anxiety disorders, depression, disruptive behavior disorders such as attention deficit hyperactivity disorder (ADHD), learning disorders, trichotillomania (compulsive hair pulling), non-verbal learning disorders, and habit disorders such as nail biting or skin picking.
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. Scientists are currently studying this to better understand the connection between streptococcus infections and OCD.
Of course, just because a child has had strep throat doesn't mean he or she will also have 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. The condition may be considered only if a child's OCD symptoms or tics are directly preceded by, or significantly worsen after, a strep infection.
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 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 they consider dirty on numerous occasions. 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 the child 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
It's important to understand that 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 is 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: November 2008
Originally reviewed by: David V. Sheslow, PhD
Note: All information is for educational purposes only. For specific medical advice,
diagnoses, and treatment, consult your doctor.
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