Pediatric Obsessive-Compulsive Disorder (OCD)

Obsessive-compulsive disorder (OCD) is a common disorder that often begins in childhood and is frequently unrecognized, underdiagnosed, and undertreated.

OCD is characterized by recurrent obsessions (unwanted ideas, thoughts, images, or urges) and compulsions (repetitive behaviors or mental acts) designed to ward off risk and/or to ease distress.  

Pediatric OCD is distinct from developmentally typical rituals of childhood such as rule-bound bedtime routines and superstitious behaviors. OCD is distinct from occasional uncomfortable thoughts and common childhood worries. It is more intense and persistent and the experience of OCD is more disturbing and senseless than everyday worries. 

Pediatric OCD has many different manifestations – concerns about germs, worrying about being responsible for harm, seeing disturbing violent images, preoccupation with luck rules, and having to have things be “just right.”  

What is consistent across the many faces of OCD is the persistent effort made to reduce uncertainty and distress. Unfortunately, these efforts actually maintain and strengthen OCD symptoms.  When left untreated, pediatric OCD has the potential to become a chronic and debilitating condition that interferes with development and persists into adulthood.

At any point in time, about 1 in every 100 adults (or between 2 to 3 million adults in the United States) has OCD. It is estimated that at least 1 in 200 children and adolescents in the United States has pediatric OCD. This is about the same number of kids who have diabetes. 

Both boys and girls are affected by pediatric OCD. Boys are more likely to have prepubescent onset (and a family history of OCD or Tourette syndrome).  Girls are more likely to develop OCD in adolescence or in their twenties.

Causes and Risk Factors

As with many behavioral or mental health conditions, the causes of OCD are not fully understood. Most experts agree that OCD is a neurobehavioral disorder, involving both brain and behavior. The brain areas most frequently implicated are the front part of the brain and deeper brain structures (called the cortical-striatal brain circuits). Serotonin is the neurotransmitter (chemical messenger) involved in these circuits.  Some evidence exists that a small subset of prepubescent children with OCD have onsets and symptom exacerbations that are associated with their immune response to certain infections (such as strep throat).

Additionally, evidence suggests that OCD runs in families, and genes likely play a role in the biologic vulnerability for this disorder for many individuals.  Interestingly, some experts view the type of OCD that emerges in childhood as having a stronger genetic component relative to OCD that emerges in adulthood.  

While differences in the brain and genes of those affected likely play a role in OCD’s development, OCD is also a learned disorder. OCD typically begins with seemingly harmless and well-intentioned behaviors designed to make uncomfortable feelings go away.  However, these ways of thinking and behavioral patterns become overlearned and strengthen over time the more they are practiced. Developing new learning about feared outcomes and one’s own abilities is a key component of effective treatment.

Symptoms and Types

Obsessions are intrusive thoughts, images, or urges that occur over and over again.  These thoughts get stuck in the affected child’s mind, like industrial strength velcro.  Children and adolescents experience these thoughts as highly disturbing and unwanted.  Understandably so, because obsessions come with uncomfortable feelings including fear, anxiety, disgust, doubt, and/or “not right” sensations.  

The following are examples of common obsessions experienced by those with OCD:

• Preoccupation with body fluids or waste, dirt, germs/disease, chemicals, or sticky substances. Fear of becoming contaminated by and/or spreading perceived contaminants.
• Preoccupation with getting sick or having an illness (e.g., vomiting, developing a disease, having cancer).
• Fear about being responsible for terrible harm if not sufficiently cautious (e.g., burning down a house, running over someone, irreparably hurting someone’s feelings).
• Unwanted thoughts (e.g., violent images, forbidden thoughts or images about sex or taboo behaviors, worries about being gay).
• Fear of losing control and doing something that is horrible or inconsistent with one’s sense of self (e.g., stealing, harming others, harming self).
• Over concern about right and wrong, having pure intentions, fear of offending God, or concerns about blasphemy.
• Superstitious ideas about luck (lucky/unlucky numbers, colors, etc.).
• Concerns about evenness, symmetry, completeness, or doing something “just right” (e.g., reading or writing, arranging).
• Need to know, remember, understand, or say, or do something perfectly.

Compulsions (also called rituals) are 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. While children might not always be able to explain their purpose, compulsions are aimed at preventing or reducing distress, and/or preventing a dreaded outcome. These compulsive behaviors are clearly excessive, however, and are not connected in a realistic way to the outcomes they intended to neutralize or prevent.

The following are examples of common compulsions experienced by those with OCD:

• Excessive hand washing, showering, grooming, cleaning or other efforts to decontaminate.
• Following rigid rules or ritualized behaviors to ensure safety.
• Checking to be sure that harm was not caused or no mistakes were made.
• Reassurance seeking, confessing, repeatedly asking questions.
• Information seeking, body checking/inspecting.
• Mental rituals such as special sayings, prayers, mentally reviewing situations.
• Doing certain tasks perfectly and/or making things “just right.”
• Repeating, counting, touching, ordering/arranging, do-overs, or undoing.

Avoidance of situations that trigger obsessions and compulsions is a very frequent response (e.g., avoid touching items, going places, thinking things). Indeed, avoidance is often the go-to response because it frequently circumvents anxiety and the perceived need to engage in time-consuming compulsive rituals.

OCD compulsions and avoidance are sometimes called “safety behaviors” because they are used to avoid risk and discomfort. OCD does not follow the rules of common sense, however, and over time these safety behaviors actually strengthen the severity of and interference from OCD.

Diagnosis and Tests

Child psychologists, child psychiatrists and other qualified behavioral health professionals usually diagnose pediatric OCD following a comprehensive diagnostic evaluation based on observation and an assessment of symptoms. A comprehensive evaluation differentiates OCD symptoms from other conditions that also involve recurrent thoughts or repetitive behaviors (e.g., other anxiety disorders, tic disorders, habits, hair pulling, skin picking, preoccupation with body or weight, autism spectrum disorder or psychosis). Additionally, a comprehensive evaluation includes assessment of frequently co-occurring conditions as well as the family’s understanding of, and participation in, the management of the child’s OCD.

OCD is diagnosed when a child or adolescent has obsessions or compulsions that are time consuming, distressing, and/or are interfering with important areas of functioning (such as at school, with friends, or at home). If the child has a tic disorder (or a history of a tic disorder), a “tic-related” specifier is applied to the OCD diagnosis.

Treatment and Care

Pediatric OCD is very treatable. The first level treatment for mild to moderate pediatric OCD is a type of cognitive behavior therapy (CBT) that emphasizes an approach called exposure and response prevention or E/RP.  When OCD symptoms are moderate to severe, or in circumstances that might impede successful CBT, a combined treatment approach (CBT plus medication management via serotonin reuptake inhibitors [SSRIs]) should be considered.

In CBT, children and parents are educated about the cycle of OCD and strategies to break free of OCD’s dead-end traps. Early CBT involves building the child and family’s readiness for engagement in the treatment. E/RP uses well-planned exposures to OCD situations combined with the child refraining from unproductive safety behaviors.  Using E/RP, children and teens learn to demote the power of their OCD thoughts, learn to increase their tolerance for discomfort, and learn to develop the “mental muscles” needed to stop engaging in all the safety behaviors that keep OCD in charge. 

Parents play a very important role in supporting successful CBT. They serve as cheerleaders who support and reinforce bravery, tolerance, and learning to live with doubt. Parents are taught how to change their engagement with their child’s OCD, including how to fade family accommodation behaviors that enable OCD symptoms.

Since OCD often co-occurs with other disorders (e.g., Tourette syndrome, AD/HD, other anxiety disorders, eating disorders), the overall treatment plan frequently needs to take these into account. Such co-occurrences might shift treatment priorities and/or result in a refinement of the recommended treatment approach. In the small subset of children whose OCD is linked to infection, the treatment for OCD is the same (CBT and/or SSRI). Antibiotics are recommended only when a child has a current active infection.

More Information and related links

International OCD Foundation - www.ocfoundation.org

Anxiety and Depression Association of America – www.adaa.org

References and Sources

American Academy of Child and Adolescent Psychiatry (2012) Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder.  Journal of the American Academy of Child and Adolescent Psychiatry, 51(1), 98-113.

National Institute of Mental Health, Pediatrics and Developmental Neurosciences Branch - Information about PANDAS – www.nimh.nih.gov