What is obsessive-compulsive disorder (OCD)?

Obsessive-compulsive disorder (OCD) is a mental health condition that causes a person to have undesirable, intrusive and recurring thoughts (obsessions) or repetitive behaviors (compulsions). The compulsions can also be thoughts or “deals” that people with OCD make with themselves. Whether they are thoughts or behaviors, all compulsions serve to neutralize obsessions. They tend to work for a little while but eventually new compulsions are needed.

Creating and following routines and rituals, and even some obsessive thoughts geared toward the experiences of their age, is often a normal part of development for children and adolescents. Preschool children often use rituals around mealtimes, bath and bedtime to help them stabilize their expectations and understanding of their world. They might insist on their favorite food, toy, book or blanket. 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 learn to socialize and master anxiety.

The obsessive thoughts and rituals of OCD have a different focus and intensity than those that occur as part of normal development. A child or teen with OCD has intrusive, undesirable thoughts typically related to fears that interrupt their ability to function in a way that is typical for their age. When unable to neutralize their distress by engaging in their compulsion the child or adolescent may become tearful, withdrawn, irritable or angry.

Children and teens suffering with OCD often struggle to be flexible, have highly specific rules about things and can become extremely angry if those rules are not adhered to. Many people are familiar with the fear of touching dirty things or being contaminated by a substance. A person struggling with this fear may avoid touching seemingly safe things or use a compulsive ritual to control these fears (such as excessive hand-washing). When a child has OCD, obsessive thoughts and compulsive rituals can become frequent and intense, interfering with daily activities and normal development.

Roughly 1 in 200 children and adolescents have OCD, but the condition is considered far more common among teens than among young children.

Causes of OCD

The cause of OCD is not known. Research indicates that OCD is a neurological disorder. People with this disorder have a deficiency of a brain chemical called serotonin. OCD tends to run in families, so this brain difference seems to have a genetic component. However, it may also develop without a family history of the condition. Recent studies suggest that streptococcal infections (strep throat) may trigger severe, sudden onset of OCD in some children, or increase the severity in other kids. 

Symptoms of OCD

Each child may experience symptoms of OCD differently, but common symptoms of the obsessive portion of the illness include:

• An extreme preoccupation with dirt, germs or contamination
• Repeated, intrusive doubts and worries (obsessing over “what if” scenarios)
• Intrusive thoughts about violence, hurting, killing someone, or harming self
• Spending long periods of time touching things, counting, or thinking about numbers and sequences
• Preoccupation with order, symmetry or exactness
• Persistent thoughts of performing repugnant sexual acts or forbidden, taboo behaviors
• Troubling 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 or causing it to happen
• Aggressive thoughts, impulses and/or behaviors

The compulsive behaviors that attempt to neutralize or relieve the obsessions are excessive, disruptive, and time-consuming, often interfering with activities and relationships. Examples of compulsive behaviors may include:

• Repeated hand-washing to the point of rawness because they “feel” dirty
• Checking and rechecking repeatedly (for example, to ensure a door is locked)
• Following rigid rules of order and becoming distressed if they are interrupted or can’t happen
• Keeping belongings in a very particular way and becoming upset if they are touched or the order gets disrupted
• Hoarding objects
• Counting and recounting excessively
• Grouping or sequencing objects
• Repeatedly asking the same questions and becoming distressed if they don’t know the “who, what, where and when”
• Repeating sounds, words, numbers and/or music to oneself
• Making “deals” with themselves (if I think/do this then that bad thing won’t happen)

The symptoms of OCD may resemble other medical conditions or neurological disorders, including Tourette syndrome. Always consult your child's doctor for a proper diagnosis.

Testing and diagnosis for OCD

If you believe your child has OCD, you can ask your pediatrician for a referral to a therapist or child psychiatrist. An early diagnosis is important for proper management of OCD, including reduced severity of symptoms and impact on your child’s life. At CHOP, a specialist will perform a comprehensive psychiatric evaluation. The evaluation may assess:

• Your child’s overall health and medical history, including exposure to strep.
• How pervasive, severe and disruptive the obsessions and compulsions are.
• How distressed your child feels or seems. Often, children don’t have the critical ability to judge their thoughts or behavior as irrational, so your child may not recognize his condition as abnormal, while you do.
• The Yale-Brown OCD Scale will likely be administered in order to have a full picture of the various types of obsessions and compulsions and how much of the day is spent engaging in them.

Treatment of OCD

Obsessive-compulsive disorder can be effectively treated through a combination of individual therapy and medication. Early diagnosis and proper treatment are key to this success. At Children’s Hospital of Philadelphia, a specialist will design a personalized treatment plan. The plan may include:

Individual therapy

• Cognitive therapy. This approach focuses on helping your child to identify obsessions and to learn new and more effective ways of tolerating and reducing them until they are resolved.
• Exposure and Response Prevention (ERP). The therapist, child and family establish a systematic, tolerable plan to help the child be able to notice the thought or impulse to engage in the behavior but refrain from engaging in the obsession. Perhaps an agreement on the maximum number of times a compulsive hand-washer may wash her hands that is rewarded, and each week the frequency is reduced.
• Management of other mental disorders your child may have. Sometimes, children with OCD also have an eating disorder, phobia or panic disorder that requires therapy, too.

Family therapy

• Parents play a vital supportive role in helping a child with OCD overcome fears as he/she learns better methods of managing them.
• Parents learn that their job is to be the child’s coach during the ERP and that they must tolerate their child’s distress, remind the child the distress is temporary and will go down after each time they refrain from engaging in compulsions.
• The specialist may discuss with you the need to consult with your child’s teachers and guidance counselor.

Medication

• OCD treatment starts with cognitive behavioral therapy, but some patient’s symptoms are so distressing that medication is added to help the patient be able to tolerate therapy. This is called combination therapy.
• The medications used to treat OCD are classified as selective serotonin reuptake inhibitors (SSRIs), which affect specific brain chemicals involved in OCD. If OCD is found to be linked to a strep infection, then a series of antibiotic medications may be prescribed.

Outlook for children with OCD

Some research has shown that about half of children with OCD are only mildly affected years after treatment. The other half have either chronic or episodic OCD but their symptoms are greatly reduced with medication and psychotherapy. Because the disorder can affect a child’s behavior and ability to function, children who are properly treated do better in their lives and relationships.

Follow-up care for children with OCD

Depending on your child’s personalized treatment plan, your child may meet with the specialist for several months or longer. If psychotherapy is phased out at a later point, medication may continue. The therapist will typically provide written exposure and response prevention plans and coping strategies to use to tolerate an obsession instead of engaging in a compulsion. Parents can pull these plans out and review them with their child and use them again.

Engaging in CBT is hard and it is recommended that parents reward children for their hard work with a small repeatable incentive that is agreed upon by both parents. Remember, you and your child can always call for “booster sessions” even after therapy is completed.

Why choose CHOP?

An early diagnosis of OCD is important. So, too, is the proper recognition of contributing factors and other possible disorders that frequently go along with OCD. Treatment can be complex but very effective when administered by a specialist. The team at CHOP is trained to diagnose, treat and manage OCD in children, and has vast experience doing so. Our experts have the skill set to lead your child to long-term success.