What is Obsessive-Compulsive Disorder (OCD)?
Obsessive-compulsive disorder is an anxiety disorder in which a person has an unreasonable thought, fear or worry that they may try to manage by performing a ritual activity to reduce the anxiety. Frequently occurring and disturbing thoughts or images are called obsessions, and the repeated rituals performed to try to prevent or dispel the discomfort they cause are called compulsions. Problems arise as the behaviors interfere with daily life functioning, school or job performance and managing personal relationships.
An individual with OCD has obsessive thoughts that are unwanted and related to fears (such as a fear of touching dirty objects) and uses compulsive rituals to control the fears (such as excessive handwashing).
When OCD is present, obsessive thoughts cause distress, and compulsions can become so frequent or intense that they interfere with activities of daily living (ADLs) and normal developmental activities. While the compulsions reduce distress in the short-term, many people describe the compulsions as unwanted or distressing in and of themselves.
During the normal growth and developmental process of children and adolescents, rituals and obsessive thoughts normally occur with a purpose and focus based on age. Preschool children often use rituals and routines around mealtimes, bath time and bedtime to help them stabilize their expectations and understanding of their world.
School-aged children normally develop group rituals as they learn to play games, team sports and recite rhymes. Older children and teens begin to collect objects and develop hobbies.
It is important to note the difference between common understandings of OCD and the actual variety and severity with which it can happen. Most people engage in some compulsive behavior or have a unique fear; when these do not cause significant interference with daily life or if disruption of these behaviors does not cause significant distress, these may be individual differences in the normal range of human behavior.
What Causes Obsessive-Compulsive Disorder?
The cause of OCD is not known. Research shows that OCD is related to differences in neurological brain areas. A chemical in the brain called serotonin likely plays a role. About 20% of children and adolescents with OCD also have another family member with OCD. Genetics may account for up to 40-60% for early onset OCD. But OCD may also develop without a family history of OCD.
How Common is Obsessive-Compulsive Disorder?
About 2-3% of children or adolescents are thought to have OCD. While OCD can begin at any age, from preschool to adulthood, OCD tends to happen in one of two age ranges for youth: childhood onset between 8-12 years old and an adolescent/young adult onset.
What are Signs and Symptoms of Obsessive-Compulsive Disorder?
The following are the most common symptoms of obsessive-compulsive disorder. However, each child may experience symptoms differently. Symptoms may include:
- An extreme preoccupation with dirt, germs or contamination
- Repeated doubts (for example, whether or not the door is locked)
- Repulsive thoughts about violence, hurting, killing someone or harming self
- Spending long periods of time touching things, counting, thinking about numbers and sequences
- Preoccupation with order, symmetry or exactness
- Persistent thoughts of performing repugnant sexual acts or forbidden, taboo behaviors
- Troubled by thoughts that are against personal religious beliefs or moral values
- An extreme need to know or remember things that may be very trivial
- Excessive attention to detail
- Abnormalities with eating patterns
- Excessive worrying about something terrible happening
- Unwanted aggressive thoughts, impulses and/or behaviors
Compulsive behaviors (the repetitive rituals used to reduce anxiety caused by the obsessions) can become excessive, disruptive and time-consuming, and may interfere with daily activities and relationships. Examples of compulsive behaviors may include:
- Grooming rituals, including repeated handwashing, showering and teeth brushing
- Checking and rechecking repeatedly (for example, to ensure that a door is locked)
- Internal, mental compulsions (such as praying or “undoing” a thought) that are difficult for others to notice
- Following rigid rules of order (putting on clothes in the very same sequence every day, keeping belongings in the room in a very particular way and becoming upset if the order becomes disrupted)
- Hoarding objects
- Counting and recounting excessively
- Grouping or sequencing objects
- Repeating words spoken by self (palilalia) or others (echolalia); repeatedly asking the same questions
- Repeating sounds, words, numbers and/or music to oneself
- Compulsive or extreme avoidance of triggers
The symptoms of OCD may resemble other medical conditions or psychiatric problems, including anxiety disorders, habit disorders, and Tourette syndrome. Always consult your child's doctor for a diagnosis.
How is Obsessive-Compulsive Disorder Diagnosed?
Clinical psychologists, child/adolescent psychiatrists and other qualified mental health professionals usually diagnose anxiety disorders in children or adolescents following a comprehensive psychiatric evaluation. The gold-standard diagnostic tool for assessing OCD symptoms and severity is called the Children’s Yale-Brown Obsessive-Compulsive Scale. It may be appropriate to ask your provider if they plan on using this tool during the evaluation.
Parents who note signs of severe anxiety or obsessive or compulsive behaviors in their child or adolescent can help by seeking an evaluation and treatment. Early treatment can often prevent future problems.
For a diagnosis of OCD to be made, the obsessions and compulsions must be pervasive, severe and disruptive enough that the individual's activities of daily living and function (including school performance) are adversely affected. It is important to note that the obsessions and compulsions are ego-dystonic, meaning that the child is bothered by them.
In most cases, the activities involved with the disorder (reassurance seeking, handwashing, checking the locks on the doors, compulsive avoidance, etc.) take up more than one hour each day and cause psychological distress and impaired mental functioning.
Often, adults and some teens realize that their behaviors are unusual. However, younger children may not have the ability to judge their behavior as irrational and abnormal or may be unwilling to acknowledge this. This is called poor insight. Children and adolescents with poor insight still benefit from treatment.
How is Obsessive-Compulsive Disorder Treated?
Specific treatment for OCD will be determined by a provider based on:
- Age, overall health, and medical history
- Extent of symptoms
- Tolerance for specific medications, procedures or therapies
- Motivation for change
- Expectations for the course of the condition
OCD can be effectively treated—sometimes with a combination of individual therapy and medications. People can start being treated after a comprehensive evaluation, taking into account necessary medical, family and social histories. Family-based and individual therapy for OCD usually includes both cognitive and behavioral techniques, with the gold-standard treatment being Cognitive-Behavioral Therapy (CBT) with Exposure and Response Prevention (E/RP). E/RP helps people break the cycle of anxiety by challenging fears and building the ability to tolerate the discomfort OCD encourages them to avoid. This helps people live the life they want to live instead of missing out on what is valuable and important. (See below for a more detailed explanation.) CBT with E/RP alone has been shown to be effective in treating OCD in children, and a combination of medication and E/RP may be more appropriate for those with more severe symptoms.
Exposure and Response Prevention: Exposure includes intentionally and systematically exposing the patient to the thoughts, images, objects and situations that typically trigger obsessive thoughts and related discomfort. The goal of exposure is for the patient to learn that the distress they feel is both tolerable and temporary; they do not need to avoid this distress or the triggers. Response prevention includes making a conscious choice to resist performing the compulsive behaviors as a way to reduce the distress or discomfort. By not engaging in the compulsion, the individual learns through experience that they can tolerate the uncomfortable feelings and that those feelings eventually will go away without a compulsion. Individuals also re-learn that the feared situation, object, image, situation, and even distress, itself, is not dangerous.
Medications used most often to treat OCD are Anafranil, Luvox CR, Prozac, Paxil and Zoloft among others. Other treatment recommendations may include family support and consultation with the school. Parents, guardians and family members play an important role in any treatment process.
Can Obsessive-Compulsive Disorder Be Prevented?
Ways to prevent OCD in children are not known at this time. More research needs to be done to better understand OCD. However, early detection and intervention can reduce the severity of symptoms, enhance normal growth and development, and improve the quality of life for people with anxiety disorders. Living a lifestyle consistent with exposure therapy, such as encouraging children to try something new or persist with difficulty, can also be helpful.
A good source for more scientific information as well as support options is the International OCD Foundation (IOCDF; iocdf.org).
