We’ve all seen the television shows and movies depicting characters that have to touch things a certain number of times, wash their hands over and over, arranging things “just so”. Hollywood can make the rituals associated with obsessive-compulsive disorder seem entertaining, but for people suffering with the illness it is definitely not a laughing matter. And, while more commonly seen in adults, obsessive-compulsive disorder (OCD) can be just as disabling in children.
OCD is a type of anxiety disorder that typically involves obsessions (worries) and compulsions (rituals). The worries are usually very common thoughts, thoughts that everybody has at some point in their lives. For instance, an obsession might be “what if I accidentally stepped in front of a car?” or “I might get sick from touching that doorknob” or “I wonder if we left the stove on” or even worries about a loved one dying. For people with OCD, they cannot let the thought come and go the way other people do. Typically, the thought makes them feel anxious or guilty and they start to think about it more and more, wondering what it means that they had the thought to begin with. They wonder if maybe they really do want to step in front of a bus, or if they are going to get sick from touching that doorknob or maybe that their house will burn down because the stove may have been left on. It becomes a viscous cycle of thinking the thought and worrying about why they had the thought.
The obsessions are most commonly associated with sex, religion, health and body issues. While adults usually recognize that the worries are extreme and often irrational, many kids with OCD lack the insight to recognize this. This sometimes makes it harder to discover that a child is struggling with OCD. Also, because children and adolescents are going through a lot of developmental changes, they may be more prone to having sexual obsessions or worries about their bodies. These can be very hard for kids to talk about, especially with their parents. Usually the rituals are performed to relieve the anxiety associated with the worries. Common compulsions are washing hands, repeating tasks over and over until they’ve done it “just right”, organizing and reorganizing until it feels right and checking to be sure everything is okay. With kids, parents are often are involved with the rituals, even if by accident. For example, a child may verbally check with a parent about whether something was cleaned. If the child is having guilty feelings about the obsessive thought, they may compulsively tell a parent about it to be sure that they are not a bad person for having the thought. Usually children with OCD have multiple obsessions and compulsions, which often change and evolve as the child matures.
OCD is typically an illness that affects an entire household, even if it’s not obvious that it’s happening. Sometimes parents try to make things easier for their child by cleaning more or making sure they don’t have to touch things that cause them distress. Children with OCD may have disagreements with siblings about how their room has to be arranged, and it might cause great distress if another family member disrupts the rituals. The amount of time spent on dealing with the obsessions and compulsions can impact the quality of life for the family if it disrupts the family schedule.
Pediatric OCD affects around 1-2% of kids. When it occurs in kids, it is slightly more common in boys. Boys also tend to develop the illness a little earlier than girls, but overall the average age that OCD develops in kids is around 9 to 10 years of age. The worries and rituals could slowly develop though and not be diagnosed as OCD for a couple of years because they can be very hard to talk about. OCD does seem to have a hereditary component, especially when it begins in childhood. Kids with OCD are more likely to have a close relative with OCD than kids without the illness.
Occasionally, things begin suddenly after a streptococcus infection, known as rheumatic fever. This is controversial but falls under the category of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS) which includes OCD, tics and a movement disorder known as Sydenham’s chorea. PANDAS is very rare and still heavily debated. But, while there is debate about the diagnosis and treatment of PANDAS, it is worthwhile to consider whether a child’s symptoms began after a strep infection. In some cases of PANDAS, the obsessions and compulsions get worse after future strep infections and may require more careful monitoring during these times.
Kids with OCD are also more likely to have other psychiatric disorders, particularly ADHD and Tourette’s syndrome. The earlier the onset of OCD, the higher the risk is for ADHD and Tourette’s syndrome. OCD is also commonly seen along with other anxiety disorders. Often these kids are anxious to begin with and have more worries in general. The distress associated with the obsessions and compulsions can often cause behavioral issues and may only be recognized because the child begins getting into arguments and fights. The increased stress could lead to depression and even suicidal ideation. Sometimes an autism spectrum disorder (ASD) can appear similar to OCD. Kids with an autism spectrum disorder can have a lot of rituals such as lining things up and difficulty with transitions and things occurring out of routine. The difference usually is that kids with an ASD are happy and gratified while they are doing the rituals, not completing the ritual because of anxiety. ASD children just prefer things to be a certain way. It’s a subtle but important difference.
Initial treatment for obsessive-compulsive disorder is typically a form of psychotherapy known as cognitive behavioral therapy (CBT). Studies have shown that CBT is as effective as medication in the treatment of mild to moderate OCD. CBT is a very specialized form of therapy that focuses on how our thinking affects our behaviors and vice versa. The key to treating OCD with therapy is changing the reaction to the thoughts and stopping the vicious cycles. CBT is the recommended therapy because it teaches the child long term skills for managing the obsessions and compulsions. If the OCD is very distressing or disruptive to the child’s life, medications can be started at the same time as therapy. The FDA has approved clomipramine, fluoxetine (Prozac), sertraline (Zoloft) and fluvoxamine (Luvox) for the treatment of OCD in kids. Similar medications such as citalopram (Celexa) and paroxetine (Paxil) are sometimes used as well. Occasionally the anxiety is so profound that additional medications in the benzodiazepine or atypical antipsychotics are added.
With appropriate treatment, OCD may go away completely. Sometimes symptoms improve with treatment but worsen or return during times of high stress, big life changes or illnesses. Recognizing the symptoms early can help a lot with treating OCD. The most important thing to remember for the child with OCD is that the thoughts that they’re having are normal thoughts. Removing the guilt and shame associated with the obsessions and normalizing the thoughts can go a long way with reducing the power that the thoughts have over the child. Finding a psychotherapist that specializes in CBT is a powerful gift for a child suffering with OCD. Just remember CBT, CBT and more CBT.
