Obsessive-compulsive Disorder (OCD)

Frequently occurring disturbing thoughts or images are called obsessions, and the repeated rituals performed to try to prevent or dispel them are called compulsions.

During the normal growth and developmental processes of children and adolescents, rituals and obsessive thoughts normally occur with a purpose and focus based on age. Preschool children often use rituals and routines around mealtimes, bath, and bedtime to help them stabilize their expectations and understanding of their world. School-aged children normally develop group rituals as they learn to play games, team sports, and recite rhymes. Older children and teens begin to collect objects and develop hobbies. These rituals help children to socialize and learn to master anxiety.

A child or adolescent with OCD has obsessive thoughts that are unwanted and related to fears (such as a fear of touching dirty objects) and uses compulsive rituals to control the fears (such as excessive hand-washing). When OCD is present, obsessive thoughts cause distress and compulsive rituals can become so frequent or intense that they interfere with activities of daily living (ADLs) and normal developmental activities.

While symptoms of OCD do occur in children, it is recognized as a relatively common mental health disorder in adolescents, with up to 2 percent to 3 percent of children and adolescents having OCD. The ratio of males affected by OCD is twice that of females. The mean age of onset for pediatric OCD can be between 9 and 11 for boys, and 11 and 13 in girls. Twenty percent of children and adolescents with OCD also have another family member with OCD.

There are two hallmark symptoms of OCD, obsessions and compulsions. Individuals with the disorder may experience either symptom or both.

Obsessions are defined as recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive (bothersome), unwanted, and that most individuals find distressing. The child attempts to ignore or suppress such obsessions with some other thought or action (i.e. performing a compulsion).

The following are the most common obsessions

• An extreme preoccupation with dirt, germs, or contamination
• Repeated doubts (for example, whether or not the door is locked)
• Obtrusive thoughts about violence, hurting, killing someone, or harming self
• Preoccupation with order, symmetry, or exactness
• Persistent thoughts of performing repugnant sexual acts or forbidden, taboo behaviors
• Troubled by thoughts that are against personal religious beliefs
• An extreme need to know or remember things that may be very trivial
• Excessive attention to detail
• Excessive worrying about something terrible happening
• Spending long periods of time thinking about numbers and sequences

Compulsions are defined by repetitive behaviors or mental acts that the individual feels the need to perform in response to an obsession or according to a rule that must be applied very strictly. The behaviors or mental acts are done in order to prevent or reduce anxiety related to some dreaded event or obsession. However, the behaviors or mental acts are not connected in a realistic way with what they are aimed at preventing or neutralizing; or are clearly excessive and time-consuming. Note: Young children may not be able to understand, recognize, and identify the aims of their behaviors.

The following are common compulsive behaviors:

• Repeated and excessive hand-washing
• Checking and rechecking repeatedly (i.e., to ensure that a door is locked)
• Following rigid rules of order (i.e., putting on clothes in the very same sequence every day, keeping belongings in the room in a very particular way, and becoming upset if the order becomes disrupted)
• Hoarding objects
• Counting and recounting excessively
• Grouping or sequencing objects
• Repeating words spoken by self (palilalia) or others (echolalia); repeatedly asking the same questions
• Coprolalia (repeatedly speaking obscenities) or copropraxia (repeatedly making obscene gestures)
• Repeating sounds, words, numbers, and/or music to oneself

Note: The symptoms of OCD may resemble other medical conditions or psychiatric problems, including Tourette's syndrome. Always consult your child's physician for a diagnosis.

The cause of OCD is not known, but as is the case with many psychiatric conditions, thought to be multifactorial. Research indicates that OCD is a neurological brain disorder. Evidence suggests that people with OCD have a deficiency of a chemical in the brain called serotonin. OCD tends to run in families, suggesting a genetic component. However, OCD may also develop without a family history of OCD. Certain environmental triggers during pregnancy and/or stressful life experiences have also been associated with OCD. Recent studies suggest that streptococcal infections may trigger the onset or increase the severity of OCD.

Many children can have routines that they do in the context of normal development as discussed above. Concern should arise if you note that the thoughts and/or routines that your child engages in become excessive (i.e., taking up large portions of their time) and cause distress; or if the rituals/routines negatively impact your child’s social/interpersonal relationships, academic performance, daily mood, and/or sleep. If any of these signs are present, it is best to seek the advice of a mental health specialist and have your child evaluated.

Preventive measures to reduce the incidence of OCD in children are not known at this time. However, early detection and intervention can reduce the severity of symptoms, enhance the child's normal growth and development, and improve their quality of life.

If you are concerned that your child may have OCD, you should have him or her evaluated by a qualified mental health professional, which may include a psychiatrist, psychologist, nurse practitioner, or licensed clinical social worker. The diagnosis is made through a comprehensive psychiatric evaluation. Parents who note signs of severe anxiety or obsessive or compulsive behaviors in their child or teen should seek an evaluation right away, as early treatment can often prevent future problems.

In order for a diagnosis of OCD to be made, the obsessions and compulsions must be pervasive, severe, and disruptive enough that the child or adolescent's activities of daily living and function are adversely affected. In most cases, the activities involved with the disorder (i.e., hand-washing, checking the locks on the doors) consume more than one hour each day and cause psychological distress and impaired mental functioning. In most cases, adults realize that their behaviors are unusual to some degree. However, children and adolescents often do not have this critical ability to judge this type of behavior as irrational and abnormal.

Research shows that OCD can be most effectively treated with a combination of individual therapy and medications. Treatment should always be based on a comprehensive evaluation of the child and family.

Individual therapy usually includes both cognitive and behavioral techniques. Cognitive therapy focuses on helping the child or adolescent identify and understand their fears and learn ways to resolve or reduce their fears more effectively. Behavior techniques help the child or adolescent and their families establish contracts or guidelines to limit or change behaviors (such as establishing a maximum number of times a compulsive hand-washer may wash his/her hands).

Medications used most often to treat OCD are classified as serotonin reuptake inhibitors (SSRIs), medications that selectively affect neurotransmitters mechanisms in the central nervous system. If OCD is found to be linked to a streptococcal infection, then a series of antibiotic medications may be prescribed by your child's physician. Treatment recommendations may include family therapy and consultation with the child's school. Parents play a vital, supportive role in any treatment process.

Specific treatment for OCD will be determined by your child's clinician based on:

• Your child's age, overall health, and medical history
• Extent of your child's symptoms
• Your child's tolerance for specific medications, procedures, or therapies
• Expectations for the course of the condition
• Your opinion or preference

A substantial percentage of pediatric OCD cases will become “subclinical” over time, meaning that the symptoms will remit and/or reduce in severity so that there is no impact on daily functioning. For individuals who continue to have symptoms into adulthood, ongoing psychotherapy and medication treatment are recommended to help alleviate the impact that OCD symptoms have on daily life.

A calm, supportive family environment in which parents and/or caregivers actively support the child's coping strategies also should improve outcome.

A substantial portion of individuals with OCD will have a co-occurring psychiatric illness which can complicate the effectiveness of treatment in the child or adolescent.