Obsessive-compulsive disorder (OCD) in children

Obsessive-compulsive disorder (OCD) is an anxiety disorder. It is an illness that causes people to have unwanted thoughts (obsessions) and to repeat certain behaviors (compulsions) over and over again. We all have habits and routines in our daily lives, such as brushing our teeth before bed. However, for people with OCD, patterns of behavior get in the way of their daily lives. Most people with OCD know that their obsessions and compulsions make no sense, but they can't ignore or stop them. All kids have worries and doubts. But kids with obsessive-compulsive disorder (OCD) often can't stop worrying, no matter how much they want to. And those worries frequently compel them to behave in certain ways over and over again.

What are obsessions?
Obsessions are ideas, images and impulses that run through the person's mind over and over again. A person with OCD doesn't want to have these thoughts and finds them disturbing, but he or she can't control them. Sometimes these thoughts just come once in a while and are only mildly annoying. Other times, a person who has OCD will have obsessive thoughts all the time.
Kids with OCD become preoccupied with whether something could be harmful, dangerous, wrong, or dirty — or with thoughts about bad stuff that might happen. With OCD, upsetting or scary thoughts or images, called obsessions, pop into a person's mind and are hard to shake. Kids with OCD may also worry about things being out of "order" or not "just right." They may worry about losing "useless" items, sometimes feeling the need to collect these items.

What are compulsions?
Obsessive thoughts make people who have OCD feel nervous and afraid. They try to get rid of these feelings by performing certain behaviors according to "rules" that they make up for themselves. These behaviors are called compulsions. (Compulsive behaviors are sometimes also called rituals.) For example, a person who has OCD may have obsessive thoughts about germs. Because of these thoughts, the person may wash his or her hands repeatedly after using a public toilet. Performing these behaviors usually only makes the nervous feelings go away for a short time. When the fear and nervousness return, the person who has OCD repeats the routine all over again. Similarly, a child with OCD feels strong urges to do certain things repeatedly — called rituals or compulsions — in order to banish the scary thoughts, ward off something dreaded, or make extra sure that things are safe or clean or right. Children may have a difficult time explaining a reason for their rituals and say they do them "just because." But in general, by doing a ritual, the child with OCD is trying to feel absolutely certain that something bad won't happen.

What are some common obsessions?
The following are some common obsessions:
Fear of dirt or germs
Disgust with bodily waste or fluids
Concern with order, symmetry (balance) and precision
Worry that a task has been done poorly, even when the person knows this is not true
Fear of thinking evil or sinful thoughts
Thinking about certain sounds, images, words or numbers all the time
Need for constant reassurance
Fear of harming a family member or friend

What are some common compulsions?
The following are some common compulsions:
Cleaning and grooming, such as washing hands, showering or brushing teeth over and over again
Checking drawers, door locks and appliances to be sure they are shut, locked or turned off
Repeating, such as going in and out of a door, sitting down and getting up from a chair, or touching certain objects several times
Ordering and arranging items in certain ways
Counting over and over to a certain number
Saving newspapers, mail or containers when they are no longer needed
Seeking constant reassurance and approval

What causes OCD?
No one has found a single, proven cause for OCD. Some research shows that it may have to do with chemicals in the brain that carry messages from one nerve cell to another. One of these chemicals, called serotonin (say "seer-oh-tone-in"), helps to keep people from repeating the same behaviors over and over again. A person who has OCD may not have enough serotonin. Many people who have OCD can function better when they take medicines that increase the amount of serotonin in their brain.

Evidence is also strong that OCD tends to run in families. Many people with OCD have one or more family members who also have it or other anxiety disorders influenced by the brain's serotonin levels. Because of this, scientists have come to believe that the tendency (or predisposition) for someone to develop the serotonin imbalance that causes OCD can be inherited through a person's genes.

Signs and Symptoms of OCD
OCD in kids is usually diagnosed between the ages of 7 and 12. Since these are the years when kids naturally feel concerned about fitting in with their friends, the discomfort and stress brought on by OCD can make them feel scared, out of control, and alone.

Recognizing OCD is often difficult because kids can become adept at hiding the behaviors. It's not uncommon for a child to engage in ritualistic behavior for months, or even years, before parents know about it. Also, a child may not engage in the ritual at school, so parents might think that it's just a phase.

When a child with OCD tries to contain these thoughts or behaviors, this creates anxiety. Kids who feel embarrassed or as if they're "going crazy" may try to blend the OCD into the normal daily routine until they can't control it anymore.

It's common for kids to ask a parent to join in the ritualistic behavior: First the child has to do something and then the parent has to do something else. If a child says, "I didn't touch something with germs, did I?" the parent might have to respond, "No, you're OK," and the ritual will begin again for a certain number of times. Initially, the parent might not notice what is happening. Tantrums, overt signs of worry, and difficult behaviors are common when parents fail to participate in their child's rituals. It is often this behavior, as much as the OCD itself, which brings families into treatment.

Parents can look for the following possible signs of OCD:
raw, chapped hands from constant washing
unusually high rate of soap or paper towel usage
high, unexplained utility bills
a sudden drop in test grades
unproductive hours spent doing homework
holes erased through test papers and homework
requests for family members to repeat strange phrases or keep answering the same question
a persistent fear of illness
a dramatic increase in laundry
an exceptionally long amount of time spent getting ready for bed
a continual fear that something terrible will happen to someone
constant checks of the health of family members
reluctance to leave the house at the same time as other family members
Environmental and stress factors can trigger the onset of OCD. These can include ordinary developmental transitions (such as starting school) as well as significant losses or changes (such as the death of a loved one or moving).

Diagnosing OCD
If your child shows signs of OCD, talk to your doctor. In screening for OCD, a doctor or mental health professional will ask about your child about obsessions and compulsions in language that kids will understand, such as:
Do you have worries, thoughts, images, feelings, or ideas that bother you?
Do you have to check things over and over again?
Do you have to wash your hands a lot, more than most kids?
Do you count to a certain number or do things a certain number of times?
Do you collect things that others might throw away (like hair or fingernail clippings)?
Do things have to be "just so"?
Are there things you have to do before you go to bed?

How is OCD treated?
The most successful treatments for kids with OCD are behavioral therapy and medication. Behavioral therapy, also known as cognitive-behavioral psychotherapy (CBT), helps kids learn to change thoughts and feelings by first changing behavior. It involves exposing kids to their fears, with the agreement that they will not perform rituals, to help them recognize that their anxiety will eventually decrease and that no disastrous outcome will occur.

For example, kids who are afraid of dirt might be exposed to something they consider dirty on numerous occasions. For exposure to be successful, it must be combined with response prevention, in which the child's rituals or avoidance behaviors are blocked. For example, a child who fears dirt must not only stay in contact with the dirty object, but also must not be allowed to wash repeatedly. Some treatment plans involve having the child "bossing back" the OCD, giving it a nasty nickname, and visualizing it as something the child can control. Over time, the anxiety provoked by dirt and the urge to perform washing rituals gradually disappear. The child also gains confidence that he or she can "fight" OCD.

OCD can sometimes worsen if it's not treated in a consistent, logical, and supportive manner. So it's important to find a therapist who has training and experience in treating OCD. Just talking about the rituals and fears have not been shown to help OCD, and may actually make it worse by reinforcing the fears and prompting extra rituals. Family support and cooperation also go a long way toward helping a child cope with OCD.

Many kids can do well with behavioral therapy alone while others will need a combination of behavioral therapy and medication. Therapy can help your child and family learn strategies to manage the ebb and flow of OCD symptoms, while medication, such as selective serotonin reuptake inhibitors (SSRIs), often can reduce the impulse to perform rituals.

Helping Kids With OCD
It's important to understand that OCD is never a child's fault. Once a child is in treatment, it's important for parents to participate, to learn more about OCD, and to modify expectations and be supportive.

Kids with OCD get better at different rates, so try to avoid any day-to-day comparisons and recognize and praise any small improvements. Keep in mind that it's the OCD that is causing the problem, not the child. The more that personal criticism can be avoided, the better.
It can be helpful to keep family routines as normal as possible, and for all family members to learn strategies to help the child with OCD. It is also important to not let OCD be the "boss" of the house and regular family activities. Giving in to OCD worries does not make them go away.




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