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Obsessive Compulsive Disorder (OCD) in Children and Adolescents

OCD in children and adolescents in many ways is similar to the adult form. However, there are some important factors to consider when the onset of OCD appears earlier in life. For instance, it is ideal for parents to be actively engaged in the treatment process in youth with OCD, whereas this requires more consideration by definition in OCD treatment for adults.

OCD symptoms often vary more in children than adults. Common symptoms include morning or nighttime rituals (e.g. saying “I love you a certain number of times”), hand washing, ordering and arranging possessions, and asking repetitive questions. This can be frustrating and confusing to parents who may think making their child “feel safe and secure” is their primary role.  Because they may lack an awareness of how their own behaviors are different from those of their age peers, children often do not realize what is happening to them, or communicate effectively about it to their parents. On the other hand, children also can be very frightened of treatment and try to convince or “guilt-trip” their families not to get them needed assistance. Diagnosis is also complicated because OCD overlaps with some aspects of normal development (superstitions, for example, wanting to have the same booked to them over and over.

Especially for boys, early onset OCD is associated with increased risks for co-occurring Tic Disorders and Attention Deficit Hyperactivity Disorder (ADHD). Also, because of gender expectancies, girls may fall through the cracks when it comes to early diagnosis of OCD, indeed they seem like “the perfect little girl.” Children with OCD often feel embarrassed and may suffer from poor self-images and feel sad. They frequently feel ashamed and hide their symptoms. They can appear tired and as if they have the weight of the world on their shoulders or too adult or “philosophical” for their age. OCD in childhood often interferes with socialization and academics. When OCD symptoms appear suddenly and severely, medical evaluation to rule PANDAS (a kind of autoimmune reaction seen after a child has strep throat or other illnesses) is a good idea. As written about elsewhere on this website, however, PANDAS is a controversial subject.

Treatment of pediatric OCD must be tailored to the severity of symptoms and the developmental level of the child. While Cognitive-Behavioral Therapy (CBT), including exposure-based therapy such as Exposure and Response Prevention (ERP) is used just as with older people, for children, it is often useful to translate ERP into games and activities. The “OC Flea” concept developed by Dr. E. Katia Moritz of NBI is an example of this approach. Suppose a child has an urge to write letters perfectly and a fear that they will get sick if they do not do this. A “silly letters” game involving writing letters imperfectly can be created to address this problem. In highly complex or severe cases, intensive treatment is sometimes the only viable approach. Actually, effective pediatric OCD treatment is a fairly new development.  Retrospectively, it may seem obvious but it took a while for even expert practitioners to catch on to the prevalance of earlier-onset OCD .

Since the basic instinct of parents is to alleviate any suffering experienced by their child, the idea of purposely exposing their child- even very gradually- to their worst worries seems unnatural and distressing. However, that is exactly the idea behind ERP.  This is how it works:  Let’s say a little girl is afraid that her mother will die if she does not tap her foot according to certain “magic” numbers.  Engaging in this neutralizing behavior provides relief from her anxiety, but only temporarily.  Sadly, this cycle of avoidance will only worsen her faulty belief system and physical discomfort, in the same way that avoiding any fear- like air travel- will tend to make it worse over time.  The effect of ERP is exactly the opposite. In other words, by facing one’s fears, it is the discomfort that becomes temporary rather than misleading improvements.  ERP not only helps lessen worrisome belief systems, it works by capitalizing on the body’s natural process of habituation, which for practical purposes just means building tolerance. To understand what building tolerance means, think of a person moving to a noisy area and getting acclimated.  After a while, they are desensitized and probably barely notice the racket. Once the parents are on board (meaning they have redefined what helping OCD means) the next step is to explain this method to the child in a way that is comprehensible and also activates them to face their fears.  For example, a child who obsesses about making mistakes might be taught to confront this worry by playing a game in which making mistakes results in a higher score.  Similarly, a girl who is afraid of illnesses might be sent on a “germ hunting safari” while being encouraged to refrain from hand washing.  Another instance would be writing a scary bedtime story together with a boy who performs rituals to ward off their fears before they will go to sleep.

Adolescents with OCD have special issues relating to their developmental stage. They may be resistant to treatment just as they may be resistant to just about anything else. Since they are at the stage of identity formation, they may be prone the extremes of either adopting a “sick-role” or, conversely, having difficulty accepting the idea of having OCD altogether. They may easily get into power struggles with parents and/or siblings which exacerbate their OCD symptoms. Learning how to deal with this in constructive ways is essential but can certainly be a challenge for both adolescents and their families. Adolescents with OCD often act as if they are in charge of their parents!

The use of medication with younger individuals with OCD is a complex matter. Parents often worry, understandably, about side effects and long-term consequences. They wonder if their child is too young to receive medication. They need to be aware about how medication for one kind of condition like OCD can trigger or worsen another sort of problem like ADHD or a Tic Disorder. The most sensible way to address these concerns is to become a highly educated consumer and seek out physicians and other clinicians that are expert and experienced in these matters.

There is solid evidence that early identification and intervention can positively affect the course of OCD. Remember, OCD is a progressive and self-perpetuating condition. By interfering with the progression of OCD early and systematically, symptoms and problems that could have developed and further impact their lives might never have a chance to emerge or seriously worsen. This, of course, provides young people with OCD the best chance for future happiness, ability to function up to their potential, and an overall better quality of life. OCD in youth is a significant issue; the goal is to make it a manageable one. Many people with earlier OCD onset have gone on to meet their challenges and build lives full of purpose and success.

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