About 1 percent of children, that is, some 200,000 American children and
teenagers have OCD. In childhood OCD, a family history of OCD is more frequent
than in adult onset OCD, leading us to believe that genetic factors may play
more of a role in childhood OCD.
Months or years may pass before parents become aware that their child has a
problem because children often hide their obsessions and compulsive behaviors.
They try to suppress symptoms until they are alone, or at least until they get
home from school. Children have a very strong need to feel accepted by others,
to fit into their peer group. The strange behaviors and senseless compulsions
are embarrassing to them so they hide them.
It is best to treat OCD early. The longer it goes untreated, the more
generalized the symptoms become. They invade more and more of the child's life
and make OCD more difficult to treat . With treatment, OCD may or may not follow
the child into adulthood. Some children may have minimal symptoms as adults or
no symptoms at all. Others go into remission their symptoms disappear, but
return during adulthood. OCD often changes over time. Symptoms experienced as an
adult may be different from those experienced as a child. Why do symptoms
sometimes disappear with treatment, and then reappear later in life? No one
knows for sure, but hormones and stress may cause changes in a person's
biological makeup, and thus affect the expression of OCD symptoms.
Children and Rituals - Could It Be OCD?
At some point during the course of the disorder, adults with OCD recognize
that their obsessions and compulsions are excessive or unreasonable. This
requirement for diagnosis does not apply to children. They may lack adequate
cognitive awareness to make this judgment. When they are anxious and obsessing,
even adults with OCD may not realize they are being unreasonable.
Most children go through developmental stages characterized by compulsive
behaviors and rituals that are quite normal. These behaviors are common between
the ages of two and eight, and seem to be a response to children's needs to
control their environment and master childhood fears and anxieties. Dr.
Henrietta Leonard, who studied the relationship between children's developmental
rituals, superstitions, and OCD, wrote that between the ages of four and eight
the developmental rituals are usually most intense. Boys express their belief
that girls have "cooties," a form of imagined contamination where boys may
vehemently avoid being touched by girls. By age seven collecting things
(hoarding in OCD) becomes common. sports cards, comic books, toy figures,
jewelry and dolls are among the popular collectibles. Between the ages of seven
and eleven children's play becomes highly ritualized and rule-bound. Breaking
the rules of a game is likely to be met with cries of "No fair!" In adolescence
rituals may subside but obsessive preoccupation with an activity or a music or
sports idol is common.
Superstitions are ritual-like behaviors often seen in normal children. These
are forms of "magical thinking" in which children believe in the power of their
thoughts or actions to control events in the world. "Lucky" numbers and rhymes,
such as "step on a crack, break your Momma's back," helps to bring about a sense
of control and mastery. These normal childhood rituals advance development,
enhance socialization, and help children deal with separation anxiety. Young
children's' rituals help them develop new abilities and define their environment.
As they mature and develop into adulthood, most of these ritualistic behaviors
disappear on their own. In contrast, rituals of the child with OCD persist well
into adulthood. They are painful, disabling, and result in feelings of shame and
isolation. Attempts to stop doing the rituals result in extreme anxiety.
Parents of a child with OCD are frequently frightened, confused, and
frustrated by their child's persistence and preoccupation with cleanliness,
orderliness, or checking rituals. Often, parents react at the extremes of either
intimidation or passive enabling. If parents overreact and attempt to interrupt
the behaviors, the child may become hostile and extremely anxious. If parents
give in to the rituals, the child never learns to confront his or her fears. Out
of frustration, many parents give in to the child and may even reluctantly
assist in the rituals, for example, doing repeated loads of the child's laundry
because he insists his clothes are "contaminated."
Cleaning, Checking, Counting, and Children
Obsessions that focus on contamination are the most commonly reported
obsessions in children. Fears of contamination by dirt and germs lead to
avoidance of suspected contaminates and excessive washing. They may wash in a
self-prescribed manner, more frequently, or for excessive lengths of time.
An obsession with contamination sometimes produces the opposite effect. In
these cases, fear of contamination of body parts, personal objects, or both,
leads to a reluctance or outright refusal to touch them. Observe for untied
shoes, un-brushed teeth, sloppy clothing, and uncombed, dirty hair - especially
in a child known previously to be neat and well-groomed.
Checking compulsions are also common in children and adolescents with OCD.
They are often precipitated by fear of harm to self or others, or the child may
be troubled by extreme doubt. Checking such things as doors, light switches,
windows, electrical outlets, and appliances may take up hours every day. The
child may spend hours on an assignment that should take only an hour or feel
compelled to check and recheck answers on assignments - to the point that it
interferes with the completion of homework.
Some children with OCD have obsessions with numbers. They may have "safe" and
"unsafe" numbers, repeat actions a certain number of times, or repeatedly count
to a given number. Children may also repeat actions, such as walking through a
doorway, until it "feels right" or in a self-prescribed manner. Look for
repetitious questioning, reading sentences over and over, and numerous eraser
marks on papers from erasing and rewriting words or numbers.
Symmetry rituals may be manifested by tying and retying shoes or constantly
rearranging objects until they are even. Items must be arranged in such a way
that they appear symmetrical to the child. Many children with OCD have
difficulty wearing certain clothes. Hypersensitivities to touch, taste, smell,
and sound are common.
Fear of harming others or self, excessive moralization, and religiosity are
often seen in children with OCD. Children and teenagers with OCD frequently have
a tendency toward perfectionism and rigidity or stubbornness. They are likely to
have above normal intelligence, have a more adult-like moral code, have more
anger and guilt, be disruptive, and have a more active fantasy life.
Below is a list of signs of OCD in children to look for. Keep in mind when
reading them that, by definition, OCD symptoms must be time consuming, cause
marked distress, or significantly interfere with one's life. These are simply
signs that there may be a
problem. If you notice them, discuss them with your child in a nonthreatening
way. If OCD is suspected, consult a psychiatrist that specializes in treating
Signs of Obsessive-Compulsive Disorder in Children (Adapted and
expanded from Detecting Obsessive-Compulsive Disorder in Children and Teens, by
Cherlene Pedrick RN in Teachers in Focus, February 1999)
Being overly concerned with dirt and germs.
Frequent hand washing or grooming, often in a ritualistic manner - red,
chapped hands from excessive washing.
Long and frequent trips to the bathroom.
Avoiding playgrounds and messy art projects, especially stickiness.
Untied shoes, since they may be "contaminated."
Avoiding touching certain "unclean" things.
Excessive concern with bodily wastes or secretions.
Insistence on having things in a certain order.
Having to count or repeat things a certain number of times, having "safe"
Repeating rituals, such as going in and out of doors a certain way,
getting in and out of chairs in a certain way, or touching certain things a
fixed number of times. This may be disguised as forgetfulness or boredom.
Excessive checking of such things as doors, lights, locks, windows, and
Taking excessive time to perform tasks. You may find a lot of eraser marks
on school work.
Going over and over letters and numbers with pencil or pen.
Excessive fear of harm to self or others, especially parents.
Fear of doing wrong or having done wrong.
Excessive hoarding or collecting.
Staying home from school to complete assignments, checking work over and
Withdrawal from usual activities and friends
Excessive anxiety and irritability if usual routines are interrupted.
Daydreaming - the child may be obsessing.
Inattentiveness, inability to concentrate or focus (often mistaken as
Getting easily, even violently upset over minor, trivial issues.
Repetitive behaviors including aimlessly walking back and forth in the
Unexplained absences from school.
Persistent lateness to school and for appointments.
Excessive, repetitive need for reassurance for having done, thought, or
said something objectionable.
Asking for reassurance, when the answer has already been given.
Rereading and re-writing, repetitively erasing.
Help for Children with OCD
Adults usually seek treatment because OCD is interfering with their lives.
Children don't always recognize that they have a problem. They are often brought
to the doctor when they exhibit unacceptable behavior and difficulty in school.
Young people and their parents need to know there is hope and help for children
As with adults, the combined use of medication and cognitive-behavior therapy
is widely recognized as the best treatment for childhood OCD (March, 1998).
Discuss your options with your child's medical team. You may want to try CBT
alone first, or combine CBT with medication. In severe cases, you will probably
want to start medication before beginning CBT. Together, CBT and medication are
powerful tools in the struggle against OCD.
First, let's summarize medication treatment for children. A detailed
discussion of medication treatment of obsessive-compulsive disorder is beyond
the scope of this book. This is only a review.
As with adults, five medications make up the first line of defense in
medication therapy for children with OCD: Anafranil, Prozac, Zoloft, Paxil,
Luvox, and Celexa. It takes up to 12 weeks at the proper dose to determine if a
medication is going to work. If one medication doesn't work, there is a good
chance that another will. It is necessary for the child to make an attempt at
resisting OCD symptoms while the medication is being tried. This is where
cognitive-behavior therapy can be very helpful by training the child in the
techniques of confronting obsessive worries and resisting compulsions.
Children can benefit greatly from cognitive-behavior therapy (CBT) for OCD
using exposure and ritual prevention. Developed in the 1960's this
"action-oriented" approach to treatment helps children confront their OCD fears
and learn new, more appropriate responses to fear provoking situations, rather
than doing rituals. For example, a child who fears contamination by dirt or
germs learns would be asked to touch an feared object bit by bit until the child
learns that the object is not harmful or dangerous. At the same time, the
therapist works with the child to limit or even stop the compulsive handwashing
and excessive showering behaviors. Wherever the fears and avoidances occur in
real live, the CBT therapist assists the child to face those very situations.
Eventually, through practice and persistence, the child learns to tolerate
increasing degrees of "contamination" without having to resort to compulsive
behaviors. To conduct CBT properly requires a high degree of therapist training
and skill in gearing the treatment for the individual child's OCD problem.
Pediatric Autoimmune Neuropsychiatric Disorders Associated with
Streptococcal Infections (PANDAS)
Childhood onset OCD has been linked to group A beta hemolytic streptococci (GABHS),
the bacteria behind strep throat. It is thought that the body forms antineuronal
antibodies against the bacteria. These antibodies interact with basal ganglia
neural tissue. This leads to OCD symptoms or intensifying of existing symptoms.
Read more in-depth information on PANDAS by Dr. Marc Reitman.
Children whose OCD is the result of this relatively rare autoimmune reaction
of the body have significant improvement or elimination of OCD symptoms when the
strep infection is treated with antibiotics (March, 1998). It is important to
get prompt treatment for strep infections. A sudden onset or worsening of OCD
symptoms accompanied by upper respiratory distress warrants a trip to the doctor
to check for signs of strep infection.
OCD and Related Disorders
Children and teenagers with OCD often have one or more other disorders.
Tourette Syndrome, tic disorders, ADHD, learning disorders, disruptive
disorders, depression, and other anxiety disorders are the most frequently seen
disorders in children and teens with OCD. Depression tends to begin after OCD
has made its home. Possibly, it is in response to the OCD (Piacentini, 1997;
When children have one or more other disorders, it is important to coordinate
cognitive-behavior therapy for OCD with the treatments for the other disorders.
Doctors, therapists, teachers, counselors, and parents need to work as a team
with the child to gain the upper hand over OCD and its team of disorders.
Tourette Syndrome (TS) is an inherited, neurological disorder that affects
about 200,000 people in the US (Koplewicz, 1996). It is characterized by
repeated and involuntary body movements and vocal sounds. These are called tics.
Symptoms begin before age 21 and last at least one year. Boys are three to five
times more likely to have TS. It occurs in only one out of every two thousand
children, but as many as 15 percent of children have transient tics (Koplewicz,
1996). These are tics that come and go. In a minority of cases, the
vocalizations can include socially inappropriate words and phrases. This is
called coprolalia. These outbursts are neither intentional nor purposeful.
Involuntary movements can include eye blinking, repeated throat clearing or
sniffing, arm thrusting, kicking movements, shoulder shrugging, and jumping. As
many as 50% of all persons with TS also have symptoms of obsessive-compulsive
disorder (McDougle, 1997).
Many children with TS or tic disorders also have other neurobehavioral
disorders, such as ADHD or OCD. When a child has both TS and OCD, it is
important to distinguish between tics and OCD symptoms because the treatments
differ. It is often difficult to tell if a symptom is a tic or an OCD ritual.
The major difference is that a tic is preceded by a sensory feeling, while an
OCD compulsion is preceded by a thought.
Attention Deficit/Hyperactivity Disorder (ADD and ADHD)
Attention deficit hyperactivity disorder is the most common neurobehavioral
disorder in children. Affecting 3% to 5% of children, it occurs four to nine
times more often in boys (Koplewicz, 1996). Attention deficit disorder and
attention deficit hyperactivity disorder are characterized by inattention and
impulsivity - difficulty keeping attention focused on one thing and being
susceptible to a broad range of distractions. When attention deficit disorder
(ADD) is accompanied by hyperactivity - excessive uncontrollable fidgetiness and
inability to sit still to the point of interference with home and school - the
term attention deficit hyperactivity disorder (ADHD) is used. While some
children with OCD can also have ADD and ADHD, OCD symptoms are often confused
with ADD and ADHD. Children with OCD often appear inattentive and distracted
when they are focusing on obsessive thoughts. They are often misdiagnosed with
ADD and ADHD.
Portions of this chapter adapted from a continuing education course for
nurses, Obsessive Compulsive Disorder, by Cherlene Pedrick RN. It was published
in 1996 by National Center of Continuing Education, Inc.
Geller, Daniel A. 1998. Juvenile Obsessive-Compulsive Disorder. In
Obsessive-Compulsive Disorders, Practical Management, edited by Jenike, Michael,
et all. St. Louis: Mosby, Inc.
Koplewicz, Harold S. 1996. It's Nobody's Fault. New York: Times Books.
Leonard, Henrietta. 1989. Childhood Rituals and Superstitions: Developmental
and Cultural Perspective. In Obsessive-Compulsive Disorder in Children and
Adolescents, edited by Rappoport, J.L. Washington, DC: American Psychiatric
March, John and Mulle, Karen. 1998. OCD in Children and Adolescents, A
Cognitive-Behavioral Treatment Manual. New York: The Guilford Press.
McDougle, Christopher J. and Goodman, Wayne K. 1997. Combination
Treatment Strategies. In Obsessive-Compulsive Disorders: Diagnosis; Etiology;
Treatment, edited by Hollander, Eric, et all. New York: Marcel Dekker, Inc.
Piacentini, John and Grawe, Flemming. 1997. Childhood OCD. In
Obsessive-Compulsive Disorders: Diagnosis; Etiology; Treatment, edited by
Hollander, Eric, et all. New York: Marcel Dekker, Inc.
Swedo, Susan Anderson and Leonard, Henrietta. 1998. Is it "Just a Phase"? New
York: Golden Books.
Yaryura-Tobias, Jose A. and Neziroglu, Fugen A. 1997. Obsessive-Compulsive
Disorder Spectrum, Pathogenisis, Diagnosis, and Treatment. Washington DC:
American Psychiatric Press.
About this Article: The following is an abridged excerpt from The OCD Workbook -
Your Guide to Breaking Free from OCD by Bruce M. Hyman, Ph.D. and Cherry Pedrick,
R.N., and "Detecting Obsessive-Compulsive Disorder in Children and Teens," by
Cherry Pedrick, R.N. in Teachers in Focus, February 1999. Modifications in the text were
made for clarity and brevity.