OCD 101, Part 1: How it Presents in Children and Teens

By Jason Marchitto, LPC, LCADC, ACS

Parents will do anything to help their kids live happy, successful lives.  Basically, when kids hurt, parents hurt. So it stands to reason that parents will therefore do whatever is in their power to help their children feel better when they are in distress. This is a natural and healthy behavior.

However, there are times that parents, despite all their love and concern, just don’t know what to do, how to make it better, and may even inadvertently make their child’s situation worse when they jump in to save them.

This is certainly the case when children and/or teens are dealing with Obsessive Compulsive Disorder (OCD).  OCD is present in at least 3% of the population (I am willing to bet that percentage is much higher due to so many misunderstandings and misdiagnosis around this disorder) and can begin to manifest in children as young as 8 (sometimes even younger) years old.

When many people think of OCD, they think of excessive hand-washing, fear of germs, and extreme order and cleanliness.  One cannot be faulted for understanding the disorder this way because this is often how it is popularized in today’s society.  However, while these characteristics may describe some common features of classic OCD, it is a very nuanced and person specific disorder and can go misdiagnosed and mistreated for decades when it is only seen in that light.

Is it OCD??

So how does OCD manifest in children and teens and how does a parent know if that is what their child is dealing with?  People often think of their childhood and teen years as some of the most casual, fun, and carefree times of their lives.  This may be true; however, this is also a time of great uncertainty for children and teens.  Children may be starting middle school and are branching out to find their identity and sense of self.  Teens are naturally curious and rife with pressure and doubt.  If a person is prone to developing OCD (there is no one universal cause for the disorder although genetics and environment are the two biggies), this is naturally the time for it to strike and manifest itself in their lives.

While it is also natural for children and teens to engage in certain rituals as well as have anxiety during this time, OCD presents with fears that cause the child or teen to engage in behaviors called compulsions.

Compulsions are actions taken either physically or mentally that the individual may use to defuse or extinguish the anxiety that the obsessions create.  So, what’s the problem with that?  Well, compulsions keep the disorder alive and well.  Compulsions alleviate the anxiety temporarily, but the fears will quickly resurface and the child/teen may feel an unexplainable urge to perform the behavior again.  This is the OCD cycle, and the best way out of it is to stop the compulsions, which while it sounds easy, is certainly no easy task for the individual with OCD.

Wait, What are Obsessions Again?

OCD Obsessions (fears) usually start with internal statements like “What if….”.  The fear is usually something related to someone or something the child/ teen cares about.  The obsession centers around doubt and can show up as an unwanted image, phrase, feeling, thought etc., that causes distress.  Although OCD obsessions can present in countless ways and over anything, some of the more common themes for children and teens can be:

*Contamination/checking:  This is the again the classic and most talked about or culturally portrayed manifestation of OCD.  Kids with this obsession may worry about germs, sickness, toxic substances, food poisoning or even catching bad “emotions”.  Or they may check things or objects out of a fear of something bad happening if it is not done correctly.

Responsibility Obsessions:  This kind of obsessions typically focus on a sense of over responsibility to protect others.  This can be people they love or compete strangers.  If compulsions are not performed, the child or teen may feel a lot of guilt about not doing enough to “protect” those around them.

Magical Thinking:  Many times, children and teens may have obsessions that sound superstitious.  For example, “If I don’t get dressed into my uniform a certain way for practice, I will lose the game”.

“Just right” Feelings-This obsession is not so much a thought of “what if…” or of an image but more of a feeling that causes distress.  Therefore, a child may keep walking a certain way or doing certain things until it just “feels right”.  Compulsions may also be mental such as repeating a certain word, phrase or image until it also “feels right”.  This can be very time-consuming.

Obsessions may also be around less spoken “taboo”, “inappropriate” or scary content.  These can be fears related to violent, sexual, moral, religious, existential or relationship thoughts, images, phrases etc. There is no limit to the content of the obsession. Compulsions to content like this may be unobservable as it occurs in their head and is often not addressed because it is very scary for the child/teen to talk about them.  It is important to note that these obsessions say absolutely nothing about the intent, desire or nature of the individual having them.  They are ego-dystonic which basically means the OCD obsessions go against the very things the child/teen may truly value.

What to Look For:

Some compulsions that may be seen in children and teens may look like:

  • Taking an excessive amount of time to complete homework or chores.  If a child is repeating reading lines or sentences in a book or consistently erasing and re-writing a word, letter or number, this may be compulsive.
  • If a child is late to school or having difficulty leaving the house due to checking things like doors, lights or going to the bathroom for extended periods
  • Consistent hand washing or not using certain towels.  Not using certain rooms or avoiding certain songs, words, places or people.
  • Again, while all children or teens may have bed time rituals, children with OCD will have a hard time sleeping if these routines are not completed.  They may also add on new behaviors that get in the way of going to sleep.
  • Arranging things to line up a certain way
  • Tapping or touching objects a certain number of times
  • Asking for reassurance.  This is a BIG ONE.  This will look like repetitive questions, “Did I take a shower today”, “Are you sure that I did my homework” “Did I accidentally hit you?” etc.  The questions may at first sound innocuous but they will be repetitive and sometimes pertain to something that may be obvious to the parent.
  • Remember, it is not all about checking, washing and cleaning or other physical rituals.  Mental compulsions are less obvious but very common in OCD.  A child may seem like they are in a daze or “always in their head”,( often ruminating or trying to solve an unanswerable problem in their mind), they may ask to parents to repeat things ( because they are internally preoccupied or mentally reviewing something), or be seen muttering things under their breath to themselves.

How to Help as Parents

The first thing to do is reach out for help.  OCD is treatable and the gold standard of treatment is called Exposure and Response Prevention (ERP).  Finding a therapist that understands OCD and treats it with ERP is paramount to recovery.  Basically, ERP helps the child/teen create a hierarchy of things that cause anxiety and gradually expose themselves to their obsessive fears without engaging in the compulsion.  This is called response prevention.  Over time and with the therapist’s guidance the obsessions will slowly fade and the urge to engage in the compulsive actions or thoughts will no longer be seen as important.

Additionally, as a parent you can support your child in treatment by:

  1. Validating instead of accommodating them.  Accommodating your child’s rituals feeds their OCD and makes it worse (doing rituals for them, helping them perform rituals, providing reassurance etc). Instead, validate their feelings and experiences around OCD.
  2. Understand that giving negative consequences for engaging in rituals do not work.  Punishing a child or teen when they engage in compulsions will not serve to help them stop.  It simply is not an option with OCD.
  3. While OCD is a part of those who have it, initially externalizing it and giving it a name can help a child or teen identify the thoughts, images and urges to respond that is a part of the OCD disorder and increase their self-esteem to not engage it.

With the right treatment and support at home, OCD can be managed successfully and parents can obtain their wish of helping and witnessing their children live happy and successful lives despite whatever noise OCD may bring up.

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