Children often have some habit, ritual, or worry that parents chalk up to kids being kids. Maybe they line up their toys a certain way. Or they worry about getting sick whenever someone sneezes. Or they can’t fall asleep unless they’re tucked in just so and have recited a specific prayer.
Fears, obsessions, and rigidity are all common childhood behaviors. But when do these behaviors signal obsessive-compulsive disorder?
What is OCD?
Obsessive-compulsive disorder, or OCD, is a common, chronic, and neuropsychiatric condition that affects approximately one in 100 children in the United States. OCD falls under the category of anxiety disorders. It’s characterized by obsessions—intrusive, persistent, and uncontrollable thoughts, images, urges, and compulsions—and repetitive physical and mental acts or rituals driven by the obsessions, often in the hopes of making them go away.
Left untreated, the condition can adversely affect a child’s quality of life. It’s also a risk factor for the development of other psychiatric conditions in adulthood.
What Causes OCD
While OCD can affect anyone at any age, it usually begins during childhood and adolescence. “The first signs can usually be seen in school-age children nine, 10, or 11. They can get better for a time. And then the symptoms appear again when they reach adolescence,” says Aleksandra Krunic, M.D., a psychiatrist and founder of the Child and Adult Clinical Psychiatry Center with offices in New York City and Huntington, New York.
The exact cause of OCD is not fully understood.
A condition called Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal Infections, or PANDAS for short, can also cause OCD symptoms or tics and may abruptly appear following a seemingly minor respiratory infection. (As a side note, up to 59% of children and adolescents with OCD will also experience a tic disorder—sudden motor or vocal twitches—in their lifetime.)
“Usually a parent can identify if there’s been some sort of an infection prior to the onset of these behaviors,” says Dr. Krunic.
Genetics may also play a role in the development of OCD. Studies of identical twins suggest that if one twin has OCD, there is a very high likelihood (approximately 80%) that the other twin does also.
Family genetic studies have also found a greater risk for OCD in first-degree relatives of children with OCD. Some studies have shown a 17% increased risk amongst first-degree relatives, in comparison to the 3% rate in the general population. Consequently, while parents need to be aware of the increased risk to their children, they should keep in mind that the majority of their children and relatives will be unaffected.
What OCD Looks Like in Children
OCD is more than someone simply washing their hands over and over. “Each child has their own flavor of OCD,” says Dr. Krunic. “They may not want anyone touching their toys or smartphone—worrying about dirt or because it just does not feel right. Or they can’t sit in certain chairs because someone else has touched it. The behaviors can be very individual.” Here are lists of obsessions and compulsions that may be symptoms of OCD:
Common obsessions include:
- Fear of germs or contamination
- Worrying about getting sick or dying
- Worrying about doing something wrong
- Fear of bad things happening
- Disturbing or aggressive thoughts or images about hurting themselves or others
- Taboo or forbidden thoughts involving sex or religion
- Needing things to be symmetrical or in a certain order
Common compulsions include:
- Excessive cleaning, grooming, and/or handwashing
- Ordering or arranging things in a particular way or pattern
- Repeated and excessive checking, such as seeing if the door is locked or the oven is off
- Compulsive counting or saying lucky words or numbers
- Repeating actions until they’re “just right”
- Excessive praying
- Mental exercises, such as reviewing lists
- Starting something over again and again, such as erasing and redoing homework
- Frequent apologizing or confessing
- Constantly seeking reassurance that they are safe or that everything will be okay
When to Seek Help
“Once you realize your child is getting stuck, that some of their worries are excessive, or that they can’t move on because they are involved in repetitive, seemingly unnecessary behavior, you want your child to be checked,” says Dr. Krunic. Who you approach, and the information you give them, is important to getting the correct diagnosis.
First, ask yourself the following questions:
- Is the behavior causing my child distress?
Children with OCD become distressed if they aren’t allowed to continue their repetitive behavior or if the object or focus of their obsession is taken away, says Dr. Krunic. “For normative obsessions, a child shouldn’t be getting into fits, such as crying, screaming, or being really anxious. That shouldn’t happen.”
- Is the behavior causing functional impairment?
OCD affects how a child lives his daily life. A child with OCD may have difficulty completing homework or small tasks, engaging in self-care, leaving the house, or socializing.
Depending on the obsession, going anywhere can often be difficult and time-consuming. “A child can’t get to school, for example, because he gets stuck on what he wants to wear, because maybe his colors don’t match perfectly,” says Dr. Krunic.
- Is the behavior causing disruptions for others?
Are there things you can’t get done or that take more time because your child’s obsessions or compulsions take precedence? “If everywhere you go, you’re late because the time spent occupied by the compulsion is so excessive, then it’s likely OCD,” says Dr. Krunic.
If the answer is ‘yes’ to the above questions, you’ll want to talk to your health care provider and get a formal diagnosis. OCD is often misdiagnosed—in both children and adults—as either simple anxiety or a behavioral issue, making it difficult to pinpoint exactly when the condition starts and making it more difficult to treat when a diagnosis is finally made.
Know that typical paper-and-pencil questionnaires often don’t work to screen for OCD. A good evaluation depends upon the professional having expertise in OCD. “It’s really important to look for an expert in cognitive behavior therapy or a child psychiatrist,” Dr. Krunic says.
What You Need to Know About Diagnosing OCD
It can take up to six years on average for a child to be accurately diagnosed with OCD, after a parent has approached either a medical provider or mental health provider. And that delay in diagnosis or mistreatment can make things worse.
LEARN MORE: A Parent’s Guide to Getting Good Care
Several factors contribute to the misdiagnosis of OCD in both children and adults.
- They don’t recognize their thoughts are irrational. Oftentimes, kids (and adults) assume that their fears are realistic and that others share them.
- They may feel ashamed of their thoughts and feelings. Kids may feel ashamed or confused and hesitate to disclose symptoms they feel are embarrassing. For example, common OCD thoughts involve the fear that they will touch someone in an inappropriate or sexual way or harm them somehow.
- Parents and doctors think it’s a behavioral problem. OCD can often result in explosive behavior, says Dr. Krunic, from parents and doctors not understanding that the child has no control over these obsessions and compulsions. “They think the child has behavioral issues. They try talk therapy and behavior modification and nothing works,” says Dr. Krunic. “These explosive behaviors may seem unexplainable, but there’s really an obsession or compulsion component behind them.”
Treatment for OCD requires cognitive behavior therapy, with exposure therapy being the essential ingredient. Most of the time, talk or play therapy doesn’t fit the bill. So, when children with OCD don’t receive appropriate or timely treatment, the following cascading effects can occur:
- Chronic symptoms worsen and become disabling.
- An overutilization of medical resources, such as too many doctor visits for ailments.
- Negative impacts on the rest of the family, including financial hardships, marital consequences, and stress on siblings.
Frequently, children with untreated or poorly treated OCD have a high rate of school absenteeism, and experience depression, panic, and/or social isolation.
This illustrates another reason why partnering with a child psychiatrist who has experience with OCD for diagnosis and treatment is key. “A child psychiatrist can really be the captain of the ship. They can also better manage comorbidities, such as tic disorder or Tourette’s, and provide a comprehensive treatment plan,” says Dr. Krunic.