Obsessive-Compulsive Disorder (OCD)

Obsessive-compulsive disorder (OCD) is a mental health condition that causes unwanted, intrusive thoughts, images or urges called obsessions and/or repetitive behaviors or mental acts called compulsions.

Children with OCD often feel driven to perform a behavior or mental ritual to reduce anxiety or prevent something they fear from happening. For example, a child who worries excessively about germs may repeatedly wash their hands, or a child who fears something bad will happen may repeatedly check a door lock.

OCD is more than simply being careful, organized or worried. The thoughts and rituals can become time-consuming and interfere with school, relationships, family life, sleep and other daily activities.

What Causes OCD?

There is no single cause of OCD. Research suggests that a combination of genetic, biological and environmental factors may contribute.

OCD tends to run in families, which suggests that genetics play a role. Having a family member with OCD does not mean a child will develop it, however, and OCD can occur in children with no known family history.

Researchers are also studying differences in how certain brain circuits function in people with OCD. It is not accurate to describe OCD as simply being caused by an imbalance of serotonin.

In some children, OCD symptoms may begin or worsen around the time of an infection. A condition known as PANS/PANDAS has been proposed to describe certain sudden-onset cases, including cases associated with infections. However, these conditions remain an area of ongoing research, and most children with OCD do not develop it because of a streptococcal infection.

OCD can begin during childhood or adolescence. Symptoms may change in type or severity over time.

Symptoms of OCD

OCD symptoms vary from child to child. Some children recognize that their thoughts or behaviors don't make sense but still feel unable to stop them. Younger children may have more difficulty explaining why they feel they need to perform a ritual.

Obsessions

Obsessions are unwanted, repeated thoughts, images or urges that cause anxiety or distress. Examples include:

• Fear of germs, contamination or illness
• Fear that they might hurt themselves or someone else, even though they do not want to
• Worry that something bad will happen to a family member
• Fear of making a mistake or being responsible for something terrible
• Excessive concern about order, symmetry or things being “just right”
• Religious, sexual or other taboo thoughts that feel frightening or upsetting
• Repeated doubts, such as wondering whether a door is locked or homework was completed correctly

Having an intrusive thought does not mean a child wants to act on it or is likely to do so.

Compulsions

Compulsions are repetitive behaviors or mental acts that a child feels driven to perform in response to an obsession or according to rigid rules. They are often intended to reduce anxiety or prevent a feared event.

Compulsions may include:

• Repeated hand-washing, showering or cleaning
• Checking doors, appliances, homework or other things repeatedly
• Repeating words, phrases or prayers
• Counting or touching objects a certain number of times
• Arranging or aligning objects until they feel “just right”
• Repeating an action because something does not feel complete
• Asking for repeated reassurance
• Avoiding situations, objects or people that trigger obsessive fears
• Mentally reviewing events or repeating phrases without anyone else noticing

Not all compulsions are visible. Some children experience mental compulsions, which can make OCD difficult for parents, teachers and even health care providers to recognize.

How OCD Affects Children

OCD can take up significant amounts of a child's time and attention. Children may:

• Take a long time to complete everyday tasks
• Have difficulty getting ready for school or going to bed
• Avoid activities, places or people because of their fears
• Have difficulty concentrating in school
• Become distressed when family members do not follow their rituals
• Need frequent reassurance from parents
• Have difficulty sleeping
• Experience anxiety, sadness or frustration
• Miss school or activities because of symptoms

Children may also involve family members in their rituals. For example, a child may repeatedly ask a parent the same question or require a parent to perform a particular action. This is sometimes called family accommodation and can unintentionally reinforce OCD symptoms.

Diagnosing Pediatric OCD

There is no blood test or brain scan that can diagnose OCD.

A child psychiatrist, psychologist, pediatrician or other qualified mental health professional will evaluate your child's symptoms, how often they occur and how much they interfere with daily life.

The evaluation may include:

• A detailed discussion with the child and parents
• Questions about obsessions, compulsions and avoidance
• Assessment of how symptoms affect school, relationships and family life
• Screening for anxiety, depression, ADHD, tic disorders and other conditions that may occur alongside OCD
• Assessment of whether symptoms could be better explained by another medical or mental health condition

The clinician may also use a standardized OCD assessment to measure symptom severity and track changes during treatment.

Treatment for Pediatric OCD

OCD is treatable, and many children improve significantly with appropriate treatment.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a first-line treatment for pediatric OCD. A specialized form called exposure and response prevention (ERP) is particularly effective.

During ERP, children gradually and safely face situations that trigger their OCD while learning not to perform the usual compulsion. Treatment is tailored to the child's age, symptoms and ability to participate.

Parents are often involved in treatment. They may learn how to respond to OCD symptoms without reinforcing rituals or providing excessive reassurance.

Medication

For children with moderate to severe OCD, or for children who do not improve enough with therapy alone, a doctor may recommend an SSRI (selective serotonin reuptake inhibitor).

Medication is typically used along with ongoing monitoring and may be combined with CBT/ERP. The choice of medication and dose depends on the child's age, symptoms, other health conditions and response to treatment.

Family Support

Family involvement is an important part of treatment. Parents and caregivers can learn strategies for responding to OCD without participating in compulsions or helping the disorder grow stronger.

Children may also need support at school, particularly when OCD interferes with attendance, concentration, assignments or other activities.

Living With OCD

OCD symptoms can change over time, and treatment may need to change as a child grows. With appropriate care, children can learn to manage intrusive thoughts and resist compulsions so OCD has less control over their daily lives.

Early treatment can help reduce the impact of OCD on school, relationships, family life and a child's overall well-being.