Children often have some habit, ritual, or worry that parents chalk up to kids being kids. Maybe they line up their toys a certain way. Or they worry about getting sick whenever someone sneezes. Or they can’t fall asleep unless they’re tucked in just so and have recited a specific prayer.
Fears, obsessions, and rigidity are all common childhood behaviors. But when do these behaviors signal obsessive-compulsive disorder?
What Is OCD?
Obsessive-compulsive disorder (OCD) is a common, chronic, and neuropsychiatric condition that affects approximately one in 100 children in the United States, according to the Anxiety and Depression Association of America. OCD falls under the category of anxiety disorders.
It’s characterized by:
- Obsessions: Intrusive, persistent, and uncontrollable thoughts, images, or urges
- Compulsions: Repetitive physical and mental acts or rituals that are driven by the obsessions—often in the hopes of making them go away
Left untreated, the condition can adversely affect a child’s quality of life. It’s also be a risk factor for the development of other psychiatric conditions in adulthood.
What Causes OCD
While OCD can affect anyone at any age, it usually begins during childhood and adolescence. “The first signs can usually be seen in school-age children nine, 10, or 11 years old,” says Aleksandra Krunic, MD, a psychiatrist and founder of the Child and Adult Clinical Psychiatry Center in Huntington, New York. “They can get better for a time. And then the symptoms appear again when they reach adolescence.”
The exact cause of OCD is not fully understood.
A condition called Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) can also cause OCD symptoms or tics. It may abruptly appear following a seemingly minor respiratory infection.
“Usually a parent can identify if there’s been some sort of an infection prior to the onset of these behaviors,” says Dr. Krunic.
Genetics may also play a role in the development of OCD. Studies of identical twins suggest that if one twin has OCD, there is a very high likelihood—approximately 80 percent—that the other twin does also. Family genetic studies have also found a greater risk for OCD in first-degree relatives of children with OCD.
What OCD Looks Like in Children
OCD is more than someone simply washing their hands over and over. “Each child has their own flavor of OCD,” says Dr. Krunic. “They may not want anyone touching their toys or smartphone—worrying about dirt or because it just does not feel right. Or they can’t sit in certain chairs because someone else has touched it. The behaviors can be very individual.”
Though each child will have their own obsessions and compulsions, the following can all be symptoms of OCD in children.
Common Obsessions Can Include:
- Fear of germs or contamination
- Worrying about getting sick or dying
- Worrying about doing something wrong
- Fear of bad things happening
- Disturbing or aggressive thoughts or images about hurting themselves or others
- Taboo or forbidden thoughts involving sex or religion
- Needing things to be symmetrical or in a certain order
Common Compulsions Can Include:
- Excessive cleaning, grooming, or handwashing
- Ordering or arranging things in a particular way or pattern
- Repeated and excessive checking, such as seeing if the door is locked or the oven is off
- Compulsive counting or saying lucky words
- Repeating actions until they’re “just right”
- Excessive praying
- Mental exercises, such as reviewing lists
- Starting something over again and again, such as erasing and redoing homework
- Frequent apologizing or confessing
- Constantly seeking reassurance that they are safe or that everything will be OK
When to Seek Help
“Once you realize your child is getting stuck, that some of their worries are excessive, or that they can’t move on because they are involved in repetitive, seemingly unnecessary behavior, you want your child to be checked,” says Dr. Krunic.
To get the correct diagnosis, it’s important to provide a clinician with the right information. Ask yourself these questions.
Is the Behavior Causing My Child Distress?
Children with OCD become distressed if they aren’t allowed to continue their repetitive behavior or if the object or focus of their obsession is taken away, says Dr. Krunic. “For normative obsessions, a child shouldn’t be getting into fits, such as crying, screaming, or being really anxious. That shouldn’t happen.”
Is the Behavior Causing Functional Impairment?
OCD affects how a child lives daily life. A child with OCD may have difficulty completing homework or small tasks, engaging in self-care, leaving the house, or socializing.
Depending on the obsession, going anywhere can often be difficult and time-consuming. “A child can’t get to school, for example, because he gets stuck on what he wants to wear, because maybe his colors don’t match perfectly,” says Dr. Krunic.
Is the Behavior Causing Disruptions for Others?
Are there things you can’t get done or that take more time because your child’s obsessions or compulsions take precedence? “If everywhere you go, you’re late because the time spent occupied by the compulsion is so excessive, then it’s likely OCD,” says Dr. Krunic.
If the answer is “yes” to the above questions, you’ll want to talk to your healthcare provider and get a formal diagnosis.
What You Need to Know About Diagnosing OCD
OCD is often misdiagnosed—in both children and adults—as either simple anxiety or a behavioral issue. This can make it difficult to pinpoint exactly when the condition started and also more difficult to treat when a diagnosis is finally made.
Know that typical paper-and-pencil questionnaires often don’t work to screen for OCD. A good evaluation depends upon the professional having expertise in OCD. “It’s really important to look for an expert in cognitive behavior therapy (CBT) or a child psychiatrist,” Dr. Krunic says.
Several factors contribute to the misdiagnosis of OCD in both children and adults.
They Don’t Recognize Their Thoughts Are Irrational
Both kids and adults may assume that their fears are realistic and that others share them.
They May Feel Ashamed of Their Thoughts and Feelings
Kids may feel ashamed or confused about what they are thinking or feeling. They may hesitate to disclose symptoms they feel are embarrassing. For example, common OCD thoughts involve the fear that they will touch someone in an inappropriate way or harm them somehow.
Parents and Doctors Think It’s a Behavioral Problem
OCD can often result in explosive behavior, says Dr. Krunic, from parents and doctors not understanding that the child has no control over these obsessions and compulsions. “They think the child has behavioral issues. They try talk therapy and behavior modification, and nothing works,” says Dr. Krunic. “These explosive behaviors may seem unexplainable, but there’s really an obsession or compulsion component behind them.”
What You Need to Know About Treating OCD
Treatment for OCD requires CBT, with exposure therapy being the essential ingredient. Most of the time, talk or play therapy doesn’t fit the bill.
When children with OCD don’t receive appropriate or timely treatment, a cascade of effects can occur. Chronic symptoms worsen and become disabling. This can lead to an overutilization of medical resources, such as too many doctor visits for ailments. Eventually, this can result in negative impacts on the rest of the family, including financial hardships, marital consequences, and stress on siblings.
Frequently, children with untreated or poorly treated OCD have a high rate of school absenteeism, and experience depression, panic, or social isolation.
What You Can Do
For proper diagnosis and treatment, it’s key to partner with a child psychiatrist who has experience with OCD. “A child psychiatrist can really be the captain of the ship,” says Dr. Krunic. “They can also better manage comorbidities, such as tic disorder or Tourette’s, and provide a comprehensive treatment plan.”
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