What is OCD in children?
Obsessive-compulsive disorder, or OCD, is a condition where someone fixates on dark, disruptive thoughts that seem to pop into the brain uninvited and refuse to leave. That's the obsessive part. To deal with these intrusive thoughts, the person may perform certain rituals to alleviate the stress. That's the compulsive part.
About 2% of all children experience OCD, says Eli Lebowitz, who studies and treats childhood and adolescent anxiety at the Yale School of Medicine Child Study Center, where he's an associate professor and director of the Program for Anxiety Disorders. In fact, most people with OCD start having it during childhood. "Even adults who are only diagnosed later in life usually tell you the problem started as kids," he says. It can start as young as preschool or appear in adolescence.
Obsessive symptoms of OCD in children
The obsessive part of the disease includes "intrusive thoughts, feelings or images that come into your head, and you can't get them out," Lebowitz says. "In children specifically, they often describe it as voice, a command almost, telling you something."
The contents of those obsessive thoughts can vary, from bad things that can harm the person or those they love to worries about contamination. "It could be about losing control of behavior and doing something bad, or doubts about things you have done or didn't do -- did I do homework, did I cheat on a test," Lebowitz says. "It can be sexual thoughts, though they are unpleasant and distressing, and can appear even in very immature children."
"It's a kind of barge-in thought of the worst topics you can think of -- god, the devil, suicide," says Lynne Siqueland, a psychologist at the Children's and Adult Center for OCD and Anxiety in Plymouth Meeting, Pennsylvania. "It's really scary."
Compulsive symptoms of OCD in children
Compulsions are rules of behavior to follow in a rigid and strict way, Lebowitz explains. That can manifest in touching or tapping things, checking things repeatedly, believing that certain numbers are "magical" and are good or bad, keeping things even on both sides of body or performing cleaning rituals like hand-washing.
"In some cases, there can seem to be a logical connection between the obsession and compulsion -- contamination and hand-washing, for example," he says. "But in many cases there is no logical connection -- a fear of an accident, but the ritual is also hand-washing."
Most children with OCD have "some degree of insight that their thoughts are not rational or their behaviors are obsessive," he says. "They can't stop it, though."
Causes of OCD in children
As with many mental illnesses, what causes the disorder is poorly understood. About 25% to 45% of cases seem to have a genetic component, Siqueland says. The obsessions and compulsions are associated with activity in certain parts of the brain, which is why OCD is considered a neurobiological disorder, she says.
A 2018 study in the American Journal of Psychiatry found through imaging studies that the parietal lobe, which is thought to play a role in attention, planning and response inhibition, was thinner in people with OCD. But the full picture is still unclear. "This is a neurology, biology problem," Lebowitz says. "We don't know enough about the mechanisms in action. There are areas of the brain involved with safety, completion, and they are hyperactive or underactive, and we can see difference in the brains of kids with OCD and without."
Medical treatments for OCD in children
The first OCD treatments were developed in response to this unusual activity in certain parts of the brain, Siqueland says. Medication is often used to treat OCD in both children and adults. The treatments are very similar, though the dosages are modified to be age-appropriate.
The first option is usually selective serotonin reuptake inhibitors, or SSRIs, the same type of medication used to treat many cases of depression. Most SSRI meds are effective, she says, but "Zoloft has the most data" and is often the go-to medication at the start.
Behavioral therapies for OCD in children
Many child psychiatrist and psychologists prefer to start with cognitive behavioral therapy instead of medication. Specifically, they use a technique called exposure and response prevention, or ERP.
"We deliberately expose the child, in a gradual way, to things that trigger the obsessions and compulsions, like contamination," Lebowitz explains. "We have them touch something they think is dirty, then respond by not doing the ritual -- so, not wash hands, or if they are obsessed with the number four, have them do something five times instead of four." This is the most effective child-based psychological treatment. "About half of all children get better with just therapy," he says. "We prefer to try psychological therapy first, especially with children. If it is not effective or the child can't do it, then we consider medications."
How parents can help their child with OCD.
Family members can get "sucked into" the child's obsessions and compulsions by trying to accommodate the child and make him or her feel better. "It can look like the whole family has OCD," Lebowitz says. That, however, is the worst thing they can do: "That is a natural response. You want your kid to feel better and get through the day. But a lot of research shows that accommodating doesn't help. In fact, the OCD gets worse the more you accommodate it."
Instead of accommodating the child, parents should simply be supportive. "Show your child 'I get it,' by not belittling or denying or dismissing it," he says. Say something like, "'OCD is an awful feeling to have, and I get that, but I know you can be OK, and it doesn't help you if I do it.'"
Treating parents can be as effective as treating children.
Lebowitz has even shown that just helping the parents can improve the child's symptoms. He runs a program at Yale called Supportive Parenting for Anxious Childhood Emotions, or SPACE, a parent-based treatment that reduces accommodation of childhood anxiety. He published a study this year in the Journal of the American Academy of Child & Adolescent Psychiatry that compared SPACE to CBT for the child, and found that it was as good as CBT in treating childhood anxiety disorders.
"We teach supportive responses, supportive sentences to say," Lebowitz says. "We also map out all the ways the parents are accommodating their child, pick some and make plans to reduce that accommodation and what to do differently. We also teach them how to cope with a child who might get upset or angry. The child's symptoms actually improve dramatically."
How do you know if your child has OCD?
All kids do quirky things. They may like to line up their stuffed animals just so, or put their toy soldiers in certain exact formations. But that is not OCD. A disorder is a problem that impairs the child's life and functioning. It often gets worse over time -- and perhaps most important, it causes distress to the child. "There is a big difference between preferences and rules," Siqueland says. "If you have to do it, that's different than you like to do it."
Behaviors cross the line when the child's ability to function in an age-appropriate way is impaired, Lebowitz says. "The key question to ask is, is this issue interfering with my child's ability to function normally and is it causing them distress? A kid who is happy lining up soldiers is OK. If he can't watch a movie because he has to check his soldiers, that child is experiencing distress."
What should you do if you think your child has OCD?
A problem that impairs a child's life and functioning and has persisted for a while is not likely to go away on its own, Lebowitz says. "My advice to parents is not to count on that, and rather to seek treatment. Often it will get worse rather than better."
If you're concerned and have access to psychologist, that's a good place to start, he says. You can also talk to your pediatrician or other primary care provider. "People wait a long time to get treatment, but if you ask the kids they'll say something like, 'I have been doing this since I was 5. I hate to have to do this,'" Siqueland says. "But the parent didn't think much of it. It is easier to treat it early."
The good news is that treatments for childhood OCD are often highly effective. Those same brain scans that showed abnormalities in kids with OCD often return to normal after successful treatment. "We like to say that OCD is stupid, and it will leave if you break the rituals," Siqueland says.