Obsessive-Compulsive Disorder in Children and Teens

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Obsessive-compulsive disorder is an anxiety disorder that affects countless children and adolescents. In fact, OCD is estimated to affect over one million children and adolescents in the United States (Taylor, 2016). The American Academy of Child and Adolescent Psychiatry found that obsessive-compulsive disorder (OCD) is found in as many as 1 in 200 children and usually begins in adolescence or young adulthood.

Dr. John March and Christine Benton, authors of Talking Back to OCD, state this means there are 3-4 youths with OCD in every average-size elementary school and up to 20 or 30 in every high school. According to the DSM-5, In the United States, 25% of cases start by the age of 14 (American Psychiatric Association, 2013). Studies have found that more than half of youth with an early onset of the disorder developed OCD before the age of 10 (Chabane et al., 2005).

OCD is characterized by the presence of obsessions, compulsions, or both. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM-5) defines obsessions as “recurrent and persistent thoughts, urges or images that are experienced, at some time during the disturbance, as intrusive, unwanted, and that in most individuals cause marked anxiety or distress,” and explains compulsions as “repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly (American Psychiatric Association, 2013).”

Often, the compulsions are referred to as “rituals.” For children and teens, a significant amount of fear, stress, and shame can be associated with OCD as thoughts and images can often be intrusive, disturbing, and unsettling. It is not uncommon for parents to be entirely caught off guard by the diagnosis due to their child hiding symptoms out of embarrassment, confusion, and guilt. Parents must have concrete examples of obsessions and compulsions or rituals to prevent misdiagnosis, as many of the symptoms overlap with other anxiety disorders. The DSM-5 states, “If OCD is untreated, the course is usually chronic…Onset in childhood or adolescence can lead to lifetime OCD.”

Common Obsessions

Christina Taylor, author of OCD: A Workbook for Clinicians, Children & Teens, lists common obsessions and compulsions for children and teens. It is important to note that obsessions are not mere “worry thoughts.” Obsessions preoccupy the child’s or teen’s mind and are often accompanied by urges to perform specific actions. The DSM-5 notes that the individual will attempt to ignore or suppress such thoughts, urges, or images or neutralize them with some other thought or action. Obsessions can often be experienced as a “bully in the brain” to a child.

Contamination Obsessions:

• Worry about germs or dirt
• Worries about chemicals, detergents, cleaners
• Worry about animals or insects

Ordering and Arranging Obsessions:

• Worry about things or actions being balanced
• Worry about things being neat
• Worry about things being aligned
• Worry about the placement of things

Collecting and Hoarding Obsessions

• Collecting and saving things, usually useless objects
• Too much concern with losing things
• Picking up useless or worthless objects
• Not throwing things away

Harming Obsessions

• Unrealistic worry about hurting someone
• Unrealistic worry about hurting yourself
• Too much concern with responsibility for others

Doubting Obsessions

• Worry that you do not remember something
• Worry that you did not complete or do something
• Worry that you did something embarrassing

Moral and Religious Obsessions

• Overconcern with punishment for being bad
• Doubting whether one is a good person
• Excessive worry about impure thoughts

Common Compulsions

Remember that the purpose of compulsions or rituals is to reduce anxiety. Compulsions can be both physical and mental. One of the diagnostic criteria for OCD is that the compulsions are time-consuming, i.e., take one hour or more per day. It is not unusual for the obsessions to inform the child or teen that if the compulsion is not performed, “something bad will happen.”

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Cleaning Washing Compulsions

• Washing hands too much or for a certain number of times
• Changing clothes excessively
• Avoiding touching or close contact with people or things

Checking Compulsions

• Repeated checking that lights, stoves, computers, and so on are off
• Repeated checking that doors, windows, shades, and so on are closed
• Repeated checking of homework

Counting Compulsions

• Touching or tapping objects a specific number of times
• Counting Steps or swallows
• Counting objects in sets of specific numbers

Arranging Compulsions

• Arranging objects in a balanced way
• Arranging items, so they don’t touch one another
• Organizing objects in a specific way

Other Compulsions

• Reassurance seeking
• Thinking good thoughts to prevent bad thoughts or events
• Saying phrases, words, or numbers to prevent a bad event or to feel clean

OCD Risk Factors

It is well documented that OCD has a strong genetic component. The DSM-5 purports that the rate of OCD among first-degree relatives of adults with OCD is approximately two times that among first-degree relatives of those without the disorder. The rate is increased 10-fold when first-degree relatives of individuals experience the onset of OCD in childhood or adolescence. Other environmental and temperamental prognostic factors include higher negative emotionality, physical and sexual abuse in childhood, and other stressful or traumatic events.

Ruling Out PANDAS

If your child or young teen has suddenly developed OCD-like symptoms, it is important to take PANDAS into consideration. It’s also important to note that this is somewhat of a controversial diagnosis in the medical community. According to the National Institute of Mental Health, PANDAS is short for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections and is associated with the sudden onset of obsessions, compulsions, motor or vocal tics following a strep throat diagnosis or scarlet fever. Clinicians state that PANDAS symptoms are described as occurring “overnight” or “out of the blue."

Treatment

Exposure-based Cognitive-Behavioral Therapy (CBT) has been the first line of treatment for children and adolescents. Research shows that CBT is more effective than medication alone for treating children, and the improvements achieved through CBT are longer-lasting than those obtained through medication alone. Exposure-based CBT for OCD is exceptionally effective for children aged 7 to 17 (Taylor, 2016).

The International OCD Foundation states Exposure and Response Prevention or ERP is a type of CBT therapy that entails exposing yourself to the thoughts, images, objects, and situations that make you anxious and/or start your obsessions. The Response Prevention aspect of ERP refers to making a choice not to do a compulsive behavior once the anxiety or obsessions have been “triggered.” All of this is done under the guidance of a therapist.