Obsessive-Compulsive Disorder in Children and Teens

What is obsessive compulsive disorder?

Obsessive-compulsive disorder (OCD) is a type of anxiety disorder. If your child or teen has OCD, they have repeated, upsetting thoughts. They do the same thing over and over again to make the thoughts go away. They feel like they cannot control these thoughts or actions.

The upsetting thoughts and images are called "obsessions." Examples include a fear of germs, a fear of being hurt, a fear of hurting others, and disturbing religious or sexual thoughts.

The actions they take over and over again to make the thoughts go away are called "compulsions." Examples of these repeated actions include counting, cleaning, and checking on things.

Children with OCD may have just obsessions or just compulsions, but most often they have both. Many children with OCD know that their thoughts and actions are not normal. They may try to hide their problem from family and friends.

How does it occur?

No one knows what causes OCD, but it tends to run in families. However, more than half of those with OCD do not have a parent with a history of OCD. Children who have been diagnosed with Tourette's syndrome are more likely to develop OCD. Some studies show that parts of the brain work differently in people with OCD. OCD may develop or get worse after a strep infection. Children may show signs of OCD as early as the preschool years, but it is most commonly diagnosed when children are between the ages of 10 and 15.

OCD symptoms often increase and reduce without apparent reason. Sometimes they will disappear and not return. Often symptoms will happen only in certain places, for example, at home but not at school. They may also happen at a specific time, for example at bedtime or when children are getting ready for school.

What are the symptoms?

The kinds of obsessions and compulsions children have depend on their age. The obsessions and compulsions may change as the child gets older. Children with OCD may:

• Be unable to stop thinking about something, such as being in a car accident or that something bad is going to happen.
• Be overly concerned with cleanliness. Such children often wash their hands or brush their teeth many times a day. They may refuse to touch things with their hands, using a barrier (tissue or shirt cuff) to touch things. They may develop odd routines like turning things on and off with their feet.
• Repeat the same simple action over and over. They may put the lid on the toothpaste 20 times before they feel they are sure it's secure. Or they may turn the light switch on and off a set number of times before they are sure it is off.
• Need reassurance again that something has been done. For example, children may want to return to their room over and over to see if video games are turned off. You may need to reassure them over and over to keep them from going to their room.

Along with the main symptoms, children with OCD may:

• arrange their desk top or place at the kitchen table until it is just so
• avoid places associated with OCD symptoms
• be on guard all the time or startle easily
• fear certain times of day associated with OCD symptoms
• feel low self-esteem over not being able to control symptoms
• have rituals for walking through doors or getting up from chairs that often involve repetitive actions or an unusual posture
• have rituals related to food and eating, eat poorly, or be a very picky eater
• have trouble concentrating due to worry about OCD symptoms
• check repeatedly to make sure that clothing such as shoelaces match exactly
• check repeatedly to make sure that their locker is locked, their books are in their backpack, or their homework is in a notebook.

Children with OCD may be successful in school, but they may have trouble completing homework and papers as they focus on getting things perfect.

Children with OCD often involve family members in their rituals. For instance, they may insist that their laundry be washed multiple times, demand that parents check their homework repeatedly, or become outraged if household items are in disarray.

The children often feel helpless over not being able to stop their obsessive or compulsive behavior. When they try to stop their obsessions or compulsions, they may stop for several hours or even a few days, but it takes great effort.

How is it diagnosed?

If your child's rituals are very time consuming, cause a lot of distress, and interfere with daily life, your child may have OCD. Your child's healthcare provider or a mental health therapist will ask about the child's symptoms, medical and family history, and any medicines the child is taking. Your child may have some lab tests to rule out medical problems.

Along with OCD, children and teens may have other problems or disorders as well, such as:

• general anxiety much of the time
• depression
• post-traumatic stress disorder
• substance abuse problems, especially with marijuana, alcohol, or sedatives used in an attempt to control or avoid their symptoms.

How is it treated?

Treatment for OCD often combines both therapy and medicine.

There are several behavioral treatments that help teach children to control or stop their obsessive acts. Behavioral therapies help children stop doing the ritual without feeling anxiety about not doing it. Exposure and response prevention therapy has provided relief for many children with OCD, but it takes time and much of the work is done as homework. For example, if children wash their hands all the time because they are afraid of being dirty, the therapist might have the child touch something dirty. Then the two of them might stand at the sink without washing hands until the anxiety goes away. Children learn ways to control their body's response to anxiety, like breathing exercises. If they practice faithfully at home, gradually they find that obsessive thoughts don't make them as anxious, and that they can skip compulsive behaviors for longer periods of time.

Cognitive behavior therapy (CBT) helps children learn about what thoughts go with their urges to act or think and how to control them. CBT also teaches specific skills for managing anxiety about symptoms.

If a child has severe symptoms, both behavioral therapy and medicine may be best. Medicines such as SSRI antidepressants, antianxiety medicines, mood stabilizers, or antipsychotic medicines may help reduce the frequency of symptoms or how severe they are.

Family therapy may also be helpful. Family therapy treats the whole family rather than just the child. Children often feel very supported when parents and siblings attend therapy with them and work as a group.

It is important to have an experienced professional working with you and your child. The mental health professional treating your child may recommend continuing treatment after your child no longer has symptoms. Since OCD often comes and goes without a clear reason for stopping and starting, continued treatment is sometimes a way to prevent symptoms.

How long will the effects last?

Children may always have this disorder, but treatment can help them recognize and manage the symptoms. OCD may last for weeks or months and then disappear or reduce dramatically. However, children who have had it once are at greater risk for future OCD. It may reappear during the adult years.

What can I do to help my child?

It is very important to help your child feel supported.

• If you suspect that your child is suicidal, get professional help immediately. Thoughts of suicide are serious at any age and require prompt attention.
• Learn all about OCD so you know how to understand the unusual behavior of your child.
• Recognize that the fear is real to the child. Never belittle the fear as a way of forcing the child to overcome it. Do not criticize your child for feeling anxious or unhappy. Children may be embarrassed or worry that they are "crazy" because they are aware that their thinking and behavior is different. The support and understanding that you provide your child is very important.
• Realize that kids get better at different rates. Recognize and praise small improvements.
• Let your child talk about the scary feelings and fears of their symptoms if he or she feels ready. Do not force the issue if your child does not feel like sharing his or her thoughts
• Let your child make simple decisions when appropriate. Because OCD often makes children feel powerless, you can help by showing them that they have control over certain parts of their lives. For example, you might consider letting children decide how to spend the day, especially allowing them to pick places that feel the safest.
• You may find yourself frequently washing, or not touching things, or performing rituals to relieve the distress of the person with OCD. Talk with your child's therapist to help decide whether family members should continue to participate in the child's symptoms.
• Stay in touch with teachers, babysitters, and other people who care for your child to share information about symptoms your child may be having.
• Take care of yourself so that you are well equipped to help your child. You can't be supportive if you're neglecting your own emotional or physical health.

When should I seek professional help?

When OCD symptoms seriously interfere with school, socializing with friends, or daily activities, your child needs help. If OCD symptoms happen more than a few times in a week, get professional help. The symptoms may not go away or may get worse without professional help.

Get emergency care if your child or teenager has ideas of suicide, harming him or herself, or harming others.

For more information and support resources check:

Obsessive-Compulsive Foundation
Web site: http://www.ocfoundation.org

(Note there are local chapters of the OC Foundation in many cities)

National Institute of Mental Health
Telephone: 866-615-NIMH (6464)
Web site: http://www.nimh.nih.gov

National Mental Health Alliance
Telephone: 800-969-NMHA (6642)
Web site: http://www.nmha.org