Childhood and adolescent OCD: What’s developmentally normal and what’s obsessive-compulsive behavior?
Most, if not all, children display ritualistic or superstitious behavior at some point during their development. Around age 2, children often insist on elaborate bedtime rituals and can be very rigid about their eating and bath routines being done “just so”. Between the ages 3 and 5, children tend to engage in repetitive behaviors such as building a block tower and knocking it down or requesting a parent read the same book over and over. Between the ages 5 and 6, children can often be sticklers for rules and become very distressed if the rules of a game are broken or changed. These early childhood behaviors can be understood in terms of mastery and control, two important and healthy developmental tasks. By middle childhood, ritualistic behaviors transition to collecting, hobbies, and more focused interests. For example, children ages 6 to 11 often keep collections of various objects and enjoy arranging and re-arranging them. Often into late teens or even adulthood, children frequently engage in superstitious behavior to prevent bad things from happening such as having a lucky pair of socks, holding their breath when driving past a cemetery, or avoiding the number 13.
Telling the difference between normal developmental rituals and obsessive-compulsive behavior can be hard to do! But as a general rule, in order to be considered a disorder, the behavior must be distressing and/or impairing. Among children with Obsessive-Compulsive Disorder (OCD), there is a greater degree of rigidity about rules and a higher level of distress when their rules are broken. Children with OCD feel very anxious if they are prevented from completing a ritual and are much harder to distract from an obsessive thought. Their OCD rituals often appear odd or bizarre to adults and other children. Children without OCD, however, aren’t as greatly affected by changes to their routines, can be more easily distracted, and their rituals are more likely to “make sense.” As you can imagine, high levels of emotional distress and rigidity about rules and rituals can affect the entire family.
Parents often come to their child’s first therapy appointment with a number of pre-existing beliefs or worries about why their child has OCD. Parents may think that they caused the OCD because of stress in the family, something they did wrong during pregnancy or early childhood, or their own anxiety. These ideas may lead parents to feel guilty or to blame someone else in the family. While a child’s OCD can affect everyone in the family, it is important for parents to know that nothing they or their child “did” caused their child’s OCD. We’ll talk more about what does cause OCD later, but first, a little more information about the disorder:
- Obsessions (“worries”) are persistent thoughts, ideas, images, or impulses that keep coming into your child’s mind even though they don’t want them to. They may be unpleasant, silly, or embarrassing, and they can cause your child excessive worry and anxiety.
- Compulsions (“rituals” or “habits”) are things that your child feels they have to do although they may know that they do not make sense. They can be either mental acts (e.g., asking for reassurance, confessing, counting) or repetitive behaviors (e.g., washing, cleaning, repeating). They can be covert (e.g., checking) or observable (e.g., touching). Sometimes your child may try to stop from doing them but stopping might not be possible. Your child might feel worried or angry or frustrated until they have finished what they feel they have to do.
Michael (age 9) checks on his new baby brother repeatedly to relieve his anxiety about unwanted, distressing thoughts about hurting the baby.
Emily (age 6) washes her hands repetitively to relieve her anxiety about thoughts about getting COVID-19.
Dominic (age 15) touches the doorknob four times with his right hand and four times with his left hand before opening the front door after school to relieve his anxiety about his parents dying in a car crash on their way home from work.
Typical OCD Themes
|Common Obsessions||Common Compulsions|
|Harm to self or others||Repeating|
|Need to tell, ask, confess||Praying|
To be diagnosed with OCD, a person can have either obsessions or compulsions. The great majority have both, but it is not uncommon for young children to report only compulsions. Additionally, the symptoms must take up at least one hour per day and cause marked distress or significantly interfere with functioning at home or school. The rituals/obsessions cannot be developmentally appropriate as described above.
Development and Course of OCD
It is estimated that about one or two out of every 100 kids have OCD. That’s quite a few! In a school of over 600 like Central Grade School, there are probably 6 to 12 kids with OCD. Onset of OCD is typically gradual, with children becoming more and more bothered by their “worry” thoughts and more and more upset about their rituals being disrupted as time goes on. Additionally, OCD often co-occurs with other psychiatric disorders including tic disorders, anxiety disorders, behavior problems, and learning disorders. Further, obsessive-compulsive spectrum disorders such as trichotillomania (hair-pulling), excoriation disorder (skin-picking), and body dysmorphic disorder are also common among kids with OCD.
Sometimes OCD symptoms may appear following a bout of strep throat. If a child’s symptoms developed rapidly following strep throat, parents should speak with their pediatrician about ruling out pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). If evidence of current or past strep throat is found, their doctor may prescribe antibiotics to treat the infection and/or anti-inflammatories to calm the immune system.
OCD as a Neurobehavioral Disorder
It is very important for parents and children to understand that OCD is a neurobiological disorder. It is characterized by dysregulation in the neural circuits linking the frontal cortex of the brain to the basal ganglia. Findings of functional neuroimaging studies consistently show that the orbitofrontal cortex (OFC), anterior cingulate cortex (ACC), and caudate nucleus of patients with Obsessive-Compulsive Disorder (OCD) are hyperactive at rest, become more active when symptoms are provoked, and show less activity following treatment (Krebs & Heyman, 2015). It is not the child’s fault, or the parents, that she or he has OCD. There is nothing that the parent or child has “done” to make her or him have OCD. Simply put, the “wiring” in the child’s brain is different from that of children without OCD.
Researchers have found that serotonin, one of the neurotransmitters (“chemical messengers”) in the brain, is linked to OCD. Medications that work on serotonin can be used to help manage OCD symptoms, but their safety and effectiveness with young children have yet to be fully established. Fortunately, these biological differences have also been shown to respond to cognitive-behavioral treatments. Neuroimaging studies have shown that the abnormalities in the brain circuits of OCD patients respond to both cognitive-behavioral therapy (CBT) and pharmacological treatment with serotonin. As such, older adolescents may benefit from combined treatment with CBT and a selective-serotonin reuptake inhibitor (SSRI) such as Zoloft, Prozac, or Paxil, but CBT remains the treatment of choice for younger children.
In my private practice, I use evidence-based cognitive-behavioral treatments to safely and effectively treat childhood and adolescent OCD. For young children (ages 5-8), much of the treatment program is focused on teaching parents the tools they need to help their child. For older children and adolescents, there are parent check-ins at the beginning and/or end of each session as well as several designated parent or family sessions throughout the program to help parents best support their child’s treatment at home. In one recent study of children and adolescents with OCD, the COVID-19 pandemic has led to an increase in contamination obsessions and washing/cleaning compulsions and has worsened existing symptoms for more than half of patients. The good news, however, is that OCD is highly treatable! So if you think your child is currently suffering from OCD symptoms, I encourage you to get support for them and for yourself – after all, OCD is a disorder that often involves the whole family, whether by involving parents in a child’s complicated rituals, frequent requests for reassurance, or taking time away from other activities. More information and support for families affected by OCD can be found at the International OCD Foundation.
Dr. Rebecca Swenson is a licensed clinical psychologist and parent coach who works with children, adolescents, young adults, and families in Northern Michigan. If someone in your family is struggling with anxiety, depression, OCD, an eating disorder, or other emotional/behavioral health issues, contact Dr. Swenson today to learn more about evidence-based treatments that can help.
Family-Based Treatment for Young Children with OCD (Freeman & Garcia, 2009)
OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual (March & Mulle, 1998)
Krebs, G. & Heyman, I. (2015). Obsessive-compulsive disorder in children and adolescents. Archives of Disease in Childhood, 100, 495-499. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413836/
Tanir, Y., Karayagmurlu, A., Kaya, I., et al. (2020). Exacerbation of obsessive compulsive disorder symptoms in children and adolescents during COVID-19 pandemic. Psychiatry Research, 293, 113363. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837048/