OCD in Children & Adolescents

It is normal for children, at various stages of development, to be concerned about sameness and symmetry and having things perfect; to insist on certain bedtime routines, to develop odd superstitions and rituals like avoiding cracks in the sidewalk. But, Obsessive-Compulsive Disorder (OCD) involves much more.
Obsessions and/or compulsions cause severe discomfort and interfere with the child’s day-to-day functioning. Obsessions are recurrent and persistent thoughts, impulses, or images that are unwanted and cause marked anxiety or distress. Compulsions are repetitive behaviors or rituals, like hand washing, hoarding, keeping things in order, checking something over and over or mental acts, like counting, repeating words silently, avoiding something. The obsessions or compulsions cause significant anxiety or distress, and they interfere with the child's normal routine, academic functioning, social activities, and relationships.

OCD is surprisingly common in children. The symptoms may appear as early as age three. Childhood OCD is more common in boys than in girls, although the adult form occurs equally in both sexes.  Common types of compulsive behavior in children are washing, counting, ordering, checking, touching, making lists, reciting magic words or numbers, and praying. If not treated, symptoms tend to be lasting, although they may come and go, and specific obsessions or rituals may change.  Here are some examples: A boy buttons and unbuttons his shirt dozens of times before he is satisfied that he can wear it.  A girl constantly prays, traces letters to get them “just right,” and spends hours making sure her homework is perfect.
By definition, most adults with OCD have at some point recognized that   their obsessions or compulsions are excessive and unreasonable. But this does not apply to children because they may lack sufficient cognitive awareness to make this judgment. However, as they grow up, they may gain this awareness, but they are helpless to stop themselves. Compulsive rituals can consume hours a day and interfere with their normal activity, play, and schoolwork. At times their lives may become increasingly restricted and as a result, their development may be interrupted. These children often develop symptoms of anxiety and depression. About two-thirds of children with OCD will suffer from major depression at some time. They also have a high rate of attention deficit disorder, with its symptoms of hyperactivity, whichcan be difficult to distinguish from compulsive behavior, distractibility, and impulsiveness.

The obsessive thoughts may vary with the age of the child and may change over time. A younger child with OCD may have persistent thoughts that harm will occur to himself or a family member; for example, an intruder entering an unlocked door or window. The child may compulsively check all the doors and windows of his home after his parents are asleep in an attempt to relieve anxiety. The child may then fear that he may have accidentally unlocked a door or window while last checking and locking, and then must compulsively check over and over again.  An older child or a teenager with OCD may fear that he will become ill with germs, or contaminated food. To cope with his/her feelings, a child may develop rituals. Sometimes the obsession and compulsion are linked together and makes it hard for the child to stop.  An example of their thought can be, "I fear this bad thing will happen if I stop checking or hand washing, so I can't stop even if it doesn't make any sense."  Children and adolescents often feel shame and embarrassment about their OCD. Many fear it means they're crazy and are hesitant to talk about their thoughts and behaviors.

Treatment
The standard treatment for OCD at any age is Behavior Therapy.  Family members’ participation in therapy is usually enlisted to supervise and encourage patients. Good communication between parents and children can increase understanding of the problem and help the parents appropriately support their child.  After symptoms become less serious, later sessions may be needed to prevent relapse and cope with new obsessions and rituals as they develop. Older children may benefit from cognitive therapy.  Cognitive methods are especially useful for children who have exaggerated sense of responsibility and fear of catastrophe.

Additional therapies are muscle relaxation, deep breathing, and other techniques of anxiety management. Assertiveness training may help reduce anger, anxiety, or guilt associated with obsessional thinking. Family therapy and insight-oriented or supportive individual psychotherapy cannot cure the symptoms, but will help children and their parents cope with the consequences, including family conflict and misunderstandings.

Medication
Today, therapists who treat OCD often suggest medications as well as behavior therapy. According to the American Academy of Child and Adolescent Psychiatry, children should keep taking the drug for at least a year and sometimes indefinitely. When the drug is the only treatment, they usually relapse in a few months if they stop. Most children with OCD can be treated effectively with a combination of psychotherapy, especially cognitive and behavioral techniques, and certain medications.  Child and Adolescent Psychiatrists are specialized to prescribe the medication.  Family support and education are also central to the success of treatment.

Resources
Obsessive-Compulsive Foundation
203-315-2190 
http://www.ocfoundation.org
American Academy of Child and Adolescent Psychiatry
www.aacap.org






Dr. Khazrai is a licensed marriage & family therapist Individual, Couple and Family psychotherapy practicing in Newport Beach.

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