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Most children like to follow routines and routines. Being tucked in at bedtime by mom or having dad read a story or brushing teeth and then hair in the morning can be comforting, and the routine can ease going to bed and getting ready in the morning. Children, as well as most adults, appreciate some routine and stability in life. However there may be cause for concern if a child insists on performing time-consuming and seemingly purposeless rituals, such as washing her hands every time she touches a toy car or doll, or checking and re-checking his room to be sure everything is in a certain order before he can leave for school. Such behaviors may indicate that a child is suffering from obsessive-compulsive disorder, or OCD.

What is OCD?
People with obsessive-compulsive disorder (OCD) suffer from unwanted and intrusive thoughts that they can't seem to get out of their heads (obsessions) and feel compelled to repeatedly perform ritualistic behaviors and routines (compulsions) to try and ease their anxiety. The obsessions and compulsions take up a great deal of time and can cause significant distress. Some children and adolescents with OCD spend hours performing complicated rituals involving hand washing, counting, or checking to ward off persistent unwelcome thoughts, feelings, or images. Others live in terror that they will accidentally do something wrong, such as harm someone or throw something out by mistake. And children with OCD may feel powerless to stop their thoughts and behaviors; they may not be aware that their behaviors are irrational.

Obsessions and rituals can interfere substantially with a child's normal routine, schoolwork, family, or social activities. Left untreated, OCD can interfere with all aspects of a child's life.

How common is OCD in children?

As many as one in 100 children may suffer from OCD. The peak age for diagnosis of OCD in children is ten years old, although it can strike children as young as two or three. Boys are more likely to develop OCD before puberty, while girls tend to develop it during adolescence, when the numbers become even. OCD tends to occur in families.

What are common obsessions and compulsions in children?

Many children with OCD will suffer from a fear of contamination or germs at some point, along with a washing compulsion such as hand washing.

Common obsessions:

• Fear of harm or danger to loved one or self (i.e., if I count to five every time I talk to my father, he won't die)
  
• A need for perfection (i.e., re-writing an assignment instead of erasing a mistake)
  
• Fear of losing something valuable
  
• A need for symmetry and order
  
• Intrusive words or sounds
  
• Aggressive/sexual thoughts
  
• Religious fixations

Common compulsions:

• Washing and rewashing hands to avoid exposure to germs
  
• Arranging or ordering objects in a very specific way
  
• Repeating a name, phrase or tune
  
• Counting or touching rituals
  
• Hoarding or saving useless items
  
• Seeking reassurance or doing things until they seem perfect

What signs should you look for in a child?

It may be difficult for parents to recognize symptoms in a child, as children may go to great lengths to hide their behaviors. Sometimes symptoms may go on for months or years before a parent notices a problem. Children and adolescents may be able to resist obsessions and compulsions at school but not at home, or vice versa. The symptoms may fluctuate and be greater during a stressful period.

Common signs of OCD:

• rough, red hands from incessant washing
  
• a sudden increase in laundry
  
• an inordinately long time spent completing homework
  
• holes erased through tests or homework
  
• a sudden drop in grades, school performance
  
• pleas to family members to repeat phrases over and over again
  
• recurrent fears that something bad will happen to a family member or other loved one
  
• extreme distress or tantrums if a ritual is interrupted
  
• difficulty concentrating at school due to repetitive and intrusive thoughts
  
• social isolation or withdrawal from peers

Children and adolescents with obsessions and compulsions may have trouble verbalizing their feelings and performing their own rituals, but can find other ways to show their anxiety. For instance, a child who is taking too long to leave the house because he can't stop checking that the doors are locked may have a temper tantrum when he is reprimanded for holding up the family from getting some place on time.

How can OCD affect a child's life?

OCD can affect almost all aspects of a child's life, including their success at school, personal relationships with family and peers, and even their physical health. The constant obsessions and compulsions in children with OCD may make it difficult for them to concentrate in class and complete homework. Their seemingly odd behaviors may result in teasing from other students. Siblings and parents may feel confused, frustrated, sad or exasperated with the rituals and the disruptions they create, straining family relationships and the household dynamic. Children with OCD are also prone to physical symptoms, such as headaches, stomachaches and other stress-related ailments.

What causes OCD?

No one really knows what causes OCD in children or adults. Scientists do know OCD is a brain disorder caused by an imbalance in certain chemicals. Environmental and genetic factors also may play a role in the development of OCD. It appears to run in families, so it is not surprising when a child of one or two parents who have OCD begins showing symptoms.

OCD is not caused by stress, although a stressful event such as the death of a loved one, parents' divorce, or move to a new neighborhood can trigger the disorder.

How is OCD diagnosed?

Only a trained mental health professional can diagnose OCD in a child or adult. The diagnostic criteria for diagnosis in children are the same as adults: obsessions and compulsions must take up at least one hour of a person's day and disrupt normal functioning. A clinician should integrate information from home and school in making a diagnosis and recommending a treatment plan.

If you suspect your child has OCD or any anxiety disorder, click here to complete a test for your child. Print out the results and discuss them with your child's doctor. He or she may refer you to a mental health professional for diagnosis and treatment.

To find a searchable listing of mental health professionals in your area, click here.

What treatments are available?

OCD responds well to treatment; indivduals respond differently. Different options are available:

• Cognitive-Behavioral Therapy (CBT): A clinician helps patients become aware of their problem thoughts or behaviors and guides them to try alternative behaviors. The therapy focuses on developing positive thinking and behavior patterns, as opposed to the negative ones that trigger OCD symptoms.
  
• Exposure and Response (ERP) Therapy: A type of CBT in which a clinician exposes a child to an obsession and prevents him or her from performing rituals or avoidance behaviors for a certain period of time that increases with each session. Although this causes anxiety in the beginning, these feelings soon begin to decrease and sometimes disappear completely. A typical course of ERP treatment may take 10 to 15 weeks. On average, children will meet with their mental health provider once a week during the course of treatment.
  
• Medication: Sometimes medication such as a selective serotonin reuptake inhibitor (SSRI) is used in combination with therapy. It can often help ease the anxious symptoms that accompany exposure therapy, giving it a chance to work. The U.S. Food and Drug Administration has approved some medications for use in children. All medications must be prescribed and followed by a trained clinician.

For more information on anxiety medications and children, click here.

What to consider in seeking professional help

Seeking mental health care for your child can be a difficult process, particularlyif you don't know what questions to ask. Parents should consider the following issues and questions when deciding on a professional and a type of treatment:

• Professional's training, experience, and credentials: Consider the training of the professional and ask about his or her experience or expertise with OCD in children. Make sure the professional is licensed in your state and has the appropriate credentials.
  
• Involvement: What role will the parent have in a child's treatment? Make sure you are comfortable and understand how parents are involved.
  
• Type and format of treatment: How often will your child need to see the professional? What is the length of treatment? Parents and children should understand the scope of the treatment, the procedures used, and the frequency and duration of the sessions.
  
• Cost and insurance: Know your health insurance coverage for mental health. Ask about acceptance of insurance when you talk to professionals. It is the parents' responsibility to know their own financial resources and any insurance requirements and limitations.
  
• Location, ease of accessibility: Treatment must balance convenience with availability of the professional.
  

For more information on finding help for your child, click here.

If a child does not cooperate

A child may be uncooperative, making the process of finding effective help difficult. Keep these things in mind:

• Children may be unaware that their behavior indicates a disorder. A clinician will be able to ask the appropriate questions and help children recognize that their behaviors need to change.
  
• They may be embarrassed about their symptoms and may not volunteer information. Since their thoughts may be violent, sexual, or offensive, they are often ashamed to admit them. Phrasing questions with sensitivity and compassion can help them give answers.
  
• The family may need to be coached about what to expect and how to deal with the child. Children will benefit if the family learns about the disorder and is supportive. Family members may need to change the way they respond to a child's OCD, especially if they have assisted a child in completing rituals in the past. A clinician can help family members to find alternative ways to deal with these situations.
  

What else can the family do to help?

It is important to let children know that their OCD is not their fault. Other ways family members can help:

• Listening to the child's feelings
  
• Recognizing and praising small accomplishments
  
• Modifying expectations until symptoms improve and during stressful periods
  
• Measuring progress on the basis of individual improvement, not against some absolute standard
  
• Being flexible and trying to maintain a normal routine
  

Family members should keep in mind that the recovery process is stressful for them, too. They should build their own support network of relatives, friends, and therapists. Remember that all of the anxiety disorders are treatable, and that with proper treatment by a mental health professional, children with OCD can go on to live full, productive lives.

Do other disorders co-occur with OCD?

Some children with OCD suffer from other disorders as well, including Tourette's syndrome, attention- deficit/hyperactivity disorder (ADHD), depression, social anxiety, and panic disorder. The presence of one or more of these in children with OCD may add to social and academic difficulties. If a child appears to have problems at school or in other situations after OCD symptoms are treated, parents should consider having the child evaluated for learning disabilities and other disorders.

Recommended Reading

Visit the Online Bookstore for a selection of titles for parents of children with OCD. Click here to find a complete list.

References and Resources

Anxiety Disorders Association of America

American Academy of Childhood & Adolescent Psychiatry

Massachusetts General Hospital/MADI Resource Center

Nemours Foundation

Obsessive Compulsive Foundation

Obsessive Compulsive Foundation of Chicago