What is Obsessive-Compulsive Disorder?
Obsessive-compulsive disorder, or OCD, is a medical disorder that causes repetitive, unpleasant thoughts (obsessions) or behaviors (compulsions) that are difficult to control. Unlike ordinary worries or habits, these obsessions and compulsions may consume significant amounts of time (more than an hour per day), may interfere with a person's daily schedule, and may cause significant distress. OCD affects approximately one percent of children and adolescents. The tendency to develop this disorder involves complex genetic and environmental factors.
Examples of obsessions include recurrent concern about germ contamination, persistent worry that a family member may become sick, or excessive preoccupation with perfection or tidiness. Compulsions, also known as rituals, include repetitive behaviors (such as washing hands, checking locks) and repetitive thoughts (such as silently counting, praying, or repeating words) that the person feels must be completed. A person who has compulsions believes that performing these rituals will prevent a frightening event (for example, "If I count to three every time I talk to my mother, then she won't die").
People with obsessive-compulsive disorder may try to ignore these thoughts or avoid the behaviors but are generally unable able to do so. Whereas adults with OCD may recognize that their obsessions or compulsions are not rational, a child or adolescent may not have that awareness. top
What Does Obsessive-Compulsive Disorder Look Like in Children and Adolescents?
The thoughts and behaviors associated with obsessive-compulsive disorder are often perplexing to parents, teachers and peers. Recognizing the symptoms of obsessive-compulsive disorder may be challenging, as the symptoms can easily be misinterpreted as willful disregard, oppositionality, or meaningless worry. In addition, children and adolescents may try to hide their symptoms or may not know how to express their underlying worries. Often, a parent or teacher only sees the end result of the symptom (hours in the bathroom, extended time alone in the bedroom, or tantrums when the child cannot do something his or her way).
Symptoms may vary over time and may change in the way they appear, which can further complicate diagnosis. Children may be able to resist the obsessions and compulsions at school but not at home. The symptoms may fluctuate, with more symptoms at stressful periods and fewer symptoms at other times. Other medical conditions can mimic the disorder, and other conditions may co-occur with the disorder.
If left untreated, the condition may lead to considerable worry or limitations in other areas of the child's life. Peer relationships, school functioning, and family functioning all may suffer. Depression may develop. In some situations, in response to the extreme anxiety, social isolation, and limited activities, a child may develop thoughts of self-harm or not wanting to be alive. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis. top
► At Home
Symptoms of obsessive-compulsive disorder at home are often more intrusive than at school. Life for the child and the family can become very stressful, and all family members including the child may feel powerless to change rigid patterns of behavior.
At home, children with OCD may have a combination of the symptoms listed below.
- Repeated obsessional thoughts that they find unpleasant.
Unlike ordinary worries, these obsessions (such as fear of becoming
fatally ill) are not generally realistic. Often the child may
deny these thoughts or behaviors, or be embarrassed by them.
- Repeated actions to prevent a feared consequence (such
as hand washing to avoid germ contamination, excessive tidying
to prevent extreme discomfort or fatal consequence)
- Consuming obsessions and compulsions. The child or adolescent
is continually preoccupied with these worries (for example, a
child avoids nearly all contact with objects due to fear of contamination,
or an adolescent bathes and washes hands for hours each day).
- Extreme distress if others interrupt a ritual. Children
may have extended tantrums if a parent insists that the child
move on to the next task.
- Difficulty explaining unusual behavior. Children with
OCD may not be able to explain what their worries are or why they
feel compelled to repeat their behaviors.
- Attempts to hide obsessions or compulsions. Children
and adolescents are often ashamed of their worries or habits and
will make great efforts to keep their thoughts or rituals a secret.
- Resistance to stopping the obsessions or compulsions
(for example, parental reassurance that the child will not become
ill from touching an item does not reassure the child). Frequently,
children cannot ignore their symptoms and, instead, feel they
must continue their rituals.
- Concern that they are "crazy" because of their thoughts.
Children with OCD may recognize that they think differently than
others their age. Consequently, these children often have low
► At School
The differences in behaviors seen at home and at school can be significant. At school, students may be successful in suppressing symptoms, while they may be unable to do so at home. Families often seek treatment once symptoms affect school performance.
At school, a child with OCD may have a combination of the symptoms listed below.
- Difficulty concentrating, which may affect many aspects
of school activities, from following directions and completing
assignments to paying attention in class. Concentration can be
affected by persistent, repetitive thoughts that are not known
to others. Finishing work in the appropriate time can be difficult,
and just starting schoolwork can be difficult, too.
- Social isolation or withdrawal from interactions with
- Low self-esteem in social and academic activities
- Problem behaviors, such as fights or arguments, resulting
from misunderstandings between the child and peers or staff. Unusual
behaviors may be distressing to the child or peers and lead to
- Medication side effects that can interfere with school
performance. Once a child is receiving medication treatment for
OCD, the child should be monitored carefully for new mood changes
or behaviors, which could potentially reflect medication side
- Other conditions, such as Attention Deficit/Hyperactivity
Disorder (ADHD), which also may be present, compounding any
learning challenges. Having one mental health condition does
not "inoculate" the child from having other conditions as well.
- Learning disorders and cognitive problems, which are often
overlooked in this population. A child's difficulties or frustrations
in school should not be presumed to be due entirely to the OCD.
If the child still has academic difficulty after OCD symptoms
are treated, an educational evaluation for learning disabilities
should be considered. A child's repeated reluctance to attend
school may be an indicator of an undiagnosed learning disability. top
► At the Doctor's Office
A child's obsessive-compulsive symptoms often are not seen during an office visit. Clinicians may benefit from talking with parents, school staff, and other important caregivers to evaluate a child's functioning in each area to determine the underlying cause of the child's symptoms.
Clinicians may face some of the following challenges in diagnosing
and treating a child or adolescent with OCD.
- Because of the variability of symptoms and their changing
appearance as a child grows, a clinician may need to see a
child over time to determine the appropriate diagnosis
- Other conditions may look like, or may accompany, obsessive-compulsive
disorder. These conditions include eating disorders (excessive
focus on food habits and weight), phobias (excessive worry regarding
a specific object or situation, such as spiders or flying), and
psychotic disorders (preoccupation with unusual beliefs or fears).
- Additional conditions often seen with obsessive-compulsive
disorder should be considered. These include Tourette's disorder
(a condition of repetitive, distressing motor and vocal tics),
Attention Deficit/Hyperactivity Disorder (ADHD), depression, social
phobia, and panic disorder.
- Researchers have identified a possible link between strep
throat infections and the sudden onset of OCD symptoms in a very
small number of children. The condition is known as PANDAS,
an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders
Associated with Streptococcal Infections. The children usually
have dramatic, "overnight" onset of symptoms, including motor
or vocal tics, obsessions, and/or compulsions. Although this syndrome
is a rare occurrence, it makes sense for families to discuss any
recent illnesses with their child's clinician.
- Young people are often ashamed and embarrassed about their
OCD symptoms and may not volunteer information. Phrasing questions
with particular sensitivity and compassion may allow a more complete
picture of symptoms to emerge, especially since obsessions or
compulsions might involve distasteful thoughts or worries of a
- Children may be unaware, or unwilling to admit,
that their behavior may indicate symptoms of a disorder
- Families may need to be coached about what they can
reasonably expect from their child. Children who suffer from OCD
will benefit if their family understands that therapy and medicines
may reduce, but do not cure, symptoms. top
How Is Obsessive-Compulsive Disorder Treated?
Obsessive-compulsive disorder is treatable through ongoing interventions provided by a child's medical practitioners, therapists, school staff, and family. These treatments include psychological interventions (counseling), biological interventions (medicines), and accommodations at home and school that reduce sources of stress for the child. Open, collaborative communication between a child's family, school, and clinicians optimizes the care and quality of life for the child with obsessive-compulsive disorder. top
► Psychological Interventions (Counseling)
Counseling can help children with OCD, and everyone around them, to understand that OCD symptoms are caused by an illness with complex genetic and environmental origins--not by flawed attitude or personality. Counseling also can reduce the impact of symptoms on daily life. A variety of psychological interventions can be helpful, and parents should discuss their child's particular needs with their clinician to determine which psychological treatments could be most beneficial for their child.
- Cognitive Behavior Therapy (CBT) is usually recommended
for children and adolescents with obsessive-compulsive disorder.
In CBT, a young person is helped to become aware of problem behaviors
or thoughts in particular situations and is then guided by the clinician
to try alternative behaviors for those situations. With younger
patients, personifying the obsessions (for example,"Germy" to describe
the fear of germs) allows children to "fight back" against the thoughts
or behaviors that could keep them away from peers or family activities.
Cognitive behavior therapy focuses on changing behaviors and on
developing more positive thinking patterns as alternatives to the
negative thoughts that cause symptoms.
- CBT and related treatments, such as exposure response prevention and behavior therapy, are based on well-researched methods that have successfully helped children and adolescents to increase healthy behaviors and thoughts. These therapy approaches can enable people with OCD to tolerate their worries, without having to perform their rituals. Young people may benefit from behavior therapy or CBT on an ongoing basis.
- Individual psychotherapy may be useful for young people with OCD, particularly when they have ongoing stressors in their lives that make symptoms worse. Children with obsessive-compulsive disorder often carry a sense of failure, as if the illness was their fault. In many cases, they know that their disturbing thoughts and rituals are generated by their own mind, which can increase their sense of self-blame. Individual psychotherapy can help young people become aware of and address their feelings of failure and self-blame.
- Parent guidance sessions can help parents to manage their child's illness, identify effective parenting skills, learn how to function as a family despite the illness, and to address complex feelings that can arise when raising a child who has a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.
- Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting.
- School-based counseling can be effective in helping a child with OCD navigate the social, behavioral, and academic demands of the school setting. top
► Biological Interventions (Medicines)
While psychotherapy may be sufficient to treat some children with
OCD, other children's symptoms do not improve significantly with
psychotherapy alone. These children may benefit from medications.
The U.S. Food and Drug Administration (FDA) has approved Anafranil,
Luvox, Prozac (fluoxetine), and Zoloft for treating children
and adolescents with OCD. Medications approved by the FDA for other
uses and age groups are also prescribed for young people with OCD.
The FDA allows doctors to use their best judgment to prescribe medication
for conditions for which the medication has not specifically been approved.
The antidepressants Celexa, Lexapro, and Paxil, are also commonly prescribed to treat symptoms of OCD. These medications, along with Luvox, Prozac, and Zoloft, belong to a group of medications called Selective Serotonin Reuptake Inhibitors, or SSRI’s. Ananfranil, another type of antidepressant medication, has anti-obsessional properties.
Sometimes larger doses of antidepressants (up to 4 times the standard
antidepressant dose) are prescribed to improve OCD symptoms. If
OCD symptoms occur in children with autism spectrum disorders, sometimes
very low doses (for example, 1 mg of Prozac) are prescribed.
In most cases these medicines begin to be effective in reducing
symptoms after the child or adolescent has taken them for at least
2-4 weeks. Fully 12 weeks may be required in order to determine
whether the medication is going to be effective for a particular
individual. Medications should only be started, stopped, or adjusted
under the direct supervision of a trained clinician.
There is no "best" medicine to treat OCD, and it is important to
remember that medicines usually reduce rather than eliminate symptoms.
Different medicines or dosages may be needed at different times
in a child's life or to address the emergence of particular symptoms.
Successful treatment requires taking medicine daily as prescribed,
allowing time for the medicine to work, and monitoring for both
effectiveness and side effects. The family, clinician and school
should maintain frequent communication to ensure that medications
are working as intended and to monitor and manage side effects.
The following cautions should be observed when any child or adolescent
is treated with antidepressants.
- Benefits and risks should be evaluated. Questions have
arisen about whether antidepressants can cause some children or
adolescents to have suicidal thoughts. The evidence to date shows
that antidepressants, when carefully monitored, have safely helped
many children and adolescents. The latest reports on this issue
from the U.S. Food and Drug Administration can be found on its
web site at www.fda.gov.
Consideration of any medicine deserves a discussion with the prescribing
clinician about its risks and benefits.
- Careful monitoring is recommended for any child receiving
medication. Though most side effects occur soon after starting
a medicine, adverse reactions can occur months after medicines
are introduced. Agitation, restlessness, increased irritability,
or comments about self-harm should be addressed immediately with
the clinician if any of these symptoms emerge after the child
starts an antidepressant. Frequent follow-up (weekly for the first
month) is now advocated by the FDA for children starting an antidepressant.
- Some children who have OCD may also have bipolar disorder.
In some individuals with bipolar disorder, antidepressants
may initially improve depressive symptoms but can sometimes worsen
manic symptoms. While antidepressants do not "cause" bipolar
disorder, they can unmask or worsen manic symptoms.
Helpful information about specific medications can be found at
(click on "Drug Information") and in the book Straight Talk About
Psychiatric Medications for Kids (Revised Edition) by Timothy
E. Wilens, MD. top
► Interventions at Home
At home, as well as at school, providing a sympathetic and tolerant environment and making some adaptations may be helpful to aid a child or adolescent with OCD.
- Understand the illness. Understanding the nature of obsessive-compulsive disorder and its consequences will help parents sympathize with a child's struggles.
- Listen to the child's feelings. Isolation can foster depression in these children. The simple experience of being listened to empathically, without receiving advice, may have a powerful and helpful effect. Parents should not let their own worries prevent them from being a strong source of support for their child.
- Plan for transitions. Getting to school in the morning or preparing for bed in the evening may be complicated by the urge to complete rituals. Anticipating and planning for these transition times may be helpful for family members.
- Adjust expectations until symptoms improve. Helping a child make more attainable goals when symptoms are more severe is important, so that the child can have the positive experience of success.
- Praise the child's efforts to resist symptoms. Children often feel like they only hear about their mistakes. Even if improvements are small, every good effort deserves to be praised.
- Talk as a family about what to say to people outside of the family. Determine what feels comfortable for the child (for example, "I have this thing called OCD. I'm getting help for it, which is making things easier for me. I might do funny things sometimes, but we can still play together"). Even if the decision is made not to discuss this medical condition with others, having an agreed-on plan will make it easier to handle unexpected questions and minimize family conflicts.
- Understand parental limits. Fulfilling a child's extreme wishes related to symptoms (for example, showering for hours) may be neither possible nor advisable. Such well-intended efforts to support a child may actually delay the development of new coping strategies and reduce the benefits of behavior therapy. Finding the balance between supportive flexibility and appropriate limit setting is frequently challenging for parents and may be aided by the guidance of a trained professional.
- "It's the OCD talking." Taking a supportive stance in which parents, child and clinicians unite together to fight symptoms is an effective strategy to distinguish between symptoms, which are frustrating, and the child, who is doing the best he or she possibly can. Sometimes it is useful to help the child distinguish himself or herself from the illness ("It's the OCD talking"). top
► Interventions at School
There are many ways that schools can help a child with obsessive-compulsive disorder succeed in the classroom. Meetings between parents and school staff, such as teachers, guidance counselors, or nurses, will allow for collaboration to develop helpful school structure for the child. The child may need particular changes (accommodations/modifications) within a classroom.
Examples of some accommodations, modifications, and school strategies include the following:
- Check in on arrival to see if the child can succeed
in certain classes that day
- Allow more time to complete certain types of assignments
- Accommodate late arrival due to symptoms at home
- Identify ways for teachers to assist the child in breaking
out of an obsession or compulsion
- Offer strategies for the child to resist uncomfortable
- Allow the child to tape record homework if the child
cannot touch writing materials
- Give the child a choice of projects if the child has
difficulty beginning a task
- Suggest that the child change the sequence of homework problems
or projects (
for example, if the child has fears related to odd-numbers, start with even-numbered problems
- Adjust the homework load to prevent the child from becoming
overwhelmed. Academic stressors, along with other stresses, aggravate
- Anticipate issues such as school avoidance if there
are unresolved social and/or academic problems
- If the child insists on certain OCD rituals at school, work
with the child to identify less intrusive rituals (such
as tapping one desk rather than tapping every desk)
- Assist with peer interactions in order to alleviate
concerns for both the child and peers
- Be aware that transitions may be particularly difficult
for the child. Negotiate reasonable expectations for transitions
within school hours. When a child with obsessive-compulsive disorder
refuses to follow directions or to transition to the next task,
for example, the reason may be anxiety rather than intentional
- Support and reinforce behavioral strategies developed by
the clinician. This should be discussed with the child's parents
and behavior therapist. Please refer to "Psychological Interventions"
above, for details regarding behavior therapy.
- Encourage the child to help develop interventions. Enlisting
the child in the task will lead to more successful strategies
and will foster the child's ability to problem-solve.
- Please click on School-Based Interventions for a more complete list of school accommodations
for children with OCD
Flexibility and a supportive environment are essential for a student with obsessive-compulsive disorder to achieve success in school. School faculty and parents together may be able to identify difficult situations and develop remedies to reduce a child's challenges at these times. top
Many online resources and books are available to help parents,
clinicians, and educators learn more about children and adolescents
with obsessive-compulsive disorder. Click
here for a wide selection of resources. top
Information provided above on obsessive-compulsive disorder drew
from sources including:
American Psychiatric Association, Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition. Washington, DC: American
Psychiatric Association, 1994
Bostic, JQ, Bagnell, A. School Consultation. In Kaplan BJ, Sadock VA. Comprehensive Textbook of Psychiatry, 8th edition. Philadelphia: Lippincott Williams and Wilkins (in press)
Dulcan, MK, Martini DR. Concise Guide to Child and Adolescent Psychiatry, 2nd Edition. Washington, DC: American Psychiatric Association, 1999
Lewis, Melvin (ed.) Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd Edition. Philadelphia: Lippincott Williams and Wilkins, 2002
Obsessive-Compulsive Foundation, OCD in Children. Internet location: www.ocfoundation.org/ocf1040a.htm September 17, 2004 top