Recognizing What’s Normal and What’s Not
As parents, we tend to notice the quirky little things that our kids do. The way they eat corn on the cob in short rows instead of typewriter style, or insist upon wearing a certain combination of clothes. Their need to have a special blanket, stuffed animal or story before they can go to sleep. Their insistence that you must always stop for an ice cream after a visit to the doctor.
But some quirks are actually red flags pointing to obsessive behavior, specifically obsessive compulsive disorder (OCD). Researchers now believe OCD is more common in children and adolescents than previously thought, affecting an estimated 1 in every 200 young people. But it can be hard to diagnose in early childhood; kids without psychiatric conditions may show some signs or symptoms of OCD or anxiety.
To better understand OCD, we talked with Gregory Chasson, Ph.D., who for nearly 10 years has helped children who suffer from severe psychiatric disorders. As a clinical and research fellow in the Department of Psychiatry at Massachusetts General Hospital (MGH) and Harvard Medical School, Chasson is also the project director for the Longitudinal Family OCD Study and a cognitive-behavioral therapist for the OCD and Related Disorders Program at MGH.
1 What is OCD?
OCD is a mental disorder characterized by recurrent obsessions and/or compulsions that cause marked distress or interference in one’s life. Obsessions are recurrent, persistent thoughts, images or impulses that are, for the most part, senseless. Compulsions are repetitive, purposeful behaviors typically done to help alleviate the immediate distress associated with the obsessions. These compulsions typically follow certain rules and are carried out in a very specific way. OCD can impair school performance, friendships and family relationships.
The difference between normal behavior and OCD is that the disorder is distressing and causes impairment in daily functioning. Furthermore, children often lack insight and the ability to effectively communicate specific obsessions, or they try to hide their ritualistic behaviors.
2 What kinds of obsessions and compulsions are typical in OCD?
Common obsessions include issues surrounding contamination, harm to self or others, sexual or aggressive ideas or urges, symmetry, and confession or religion. Common compulsions include washing, repeating routine activities like flipping a light switch, touching objects, counting, ordering/arranging belongings, or hoarding valueless items like bottle caps.
A child may worry constantly about dirt or germs or coming down with a disease such as HIV. Adolescents may express their fear in very imaginative ways. One of my patients believed he had an “aura of badness” that could affect other people.
Sometimes, kids will have an intrusive thought, such as worrying that they will stab a friend or a parent. They will ask a lot of questions about the possibility of harming someone. Or they can become obsessed with symmetry, needing to line up shoes so they are parallel, placing books or toys just so, trying to get the “just right feeling” about how objects are arranged. Kids with OCD will become stuck on these things and suffer considerable emotional distress over them. There will be a sense that they feel compelled to do things they don’t want to do.
3 At what age can a person develop OCD?
The most common onset occurs in young adulthood, but most individuals with the disorder report that they developed early signs or symptoms in childhood. For pediatric OCD, boys are more likely to have a prepubescent onset, while girls commonly begin displaying symptoms in adolescence. Evidence indicates that children and adolescents with OCD are more likely to exhibit harm obsessions or hoarding compulsions compared to adults with the disorder. Earlier onset of OCD is also associated with an increased risk for Attention Deficit/Hyperactivity Disorder, phobias and other anxiety disorders, as well as Tourette’s Disorder.
Research has suggested that childhood-onset OCD may be more genetically based compared to those who develop OCD in adulthood. Children whose parents have OCD, anxiety or depression are at a higher risk for developing the disorder. This is why it is extremely important for current research to examine biological and environmental factors that contribute to the disorder’s onset.
4 How is a family affected when a child has OCD?
OCD is an illness that can affect the entire family. Often, children are secretive about their symptoms while in school or out in public, so it is not unusual for them to delay their rituals until they are in the home environment. It is a natural tendency for family members to become involved in reducing the suffering of their OCD relative by participating in or promoting rituals or avoidance behaviors. For example, children who obsess about germs might ask parents and siblings to clean and wash excessively, as well as acquire large amounts of soap. Children who worry about harming someone may inspire the family to get rid of all their knives. Unfortunately, accommodating these behaviors typically is not helpful. Involvement in the rituals can perpetuate a cycle whereby family members become distressed, family life is disrupted and the child’s demands for assistance increase. Family members who feel compelled to perform or promote OCD behaviors for a relative should consult with a mental health professional with experience treating OCD.
5 How can parents get help for kids with OCD?
Treatment for pediatric OCD may include psychological treatments and medication. Cognitive Behavioral Therapy (CBT) for pediatric OCD is a psychological treatment involving a collaborative approach between therapist, child and often other family members. CBT involves systematic exposure to anxiety-provoking situations or triggers, while simultaneously helping the patient abstain from rituals or avoidance behaviors.
Children with contamination obsessions might be asked to touch unclean objects as an exposure to the fear of becoming sick or dirty. At the same time, the child would be asked to refrain from any rituals, such as washing his or her hands or using gloves, while touching the unclean objects.