People often use the term OCD casually, to describe someone who is neat and likes to be organized, but that’s a vast understatement. Obsessive-compulsive disorder (OCD) is the diagnosis given when children have intrusive, persistent thoughts and compulsions that interfere with their ability to function. Rooted in anxiety, OCD can arise at any age, preschool through adulthood, but is most likely to appear in the pre-adolescent years.
What is obsessive-compulsive disorder in children?
Habits (and sometimes even compulsions) are normal, says Robert King, MD, a Yale Medicine Child Study Center psychiatrist and medical director of the Tic Disorder & Obsessive Compulsive Disorder Program. These behaviors only become a “disorder” when obsessions and compulsions cause distress to the child and family.
The worries of a child with OCD have little in common with everyday anxieties about tests or sports or friends, Dr. King says. Rather, they are “unreasonable sorts of worries that keep nagging at you,” he says, adding that “no matter how much you keep trying to do whatever it is you think you need to do to neutralize it, you can’t.”
“These children are always cleaning, always checking, always having to count,” says Dr. King. “The family has to say things in exactly just the right way. If parents touch the wrong thing or don't collaborate in helping the child perform the compulsion, the child gets very upset.”
OCD runs in families and can also be related to environmental factors, such as an overly strict upbringing, but, “We think that fundamentally it is probably biological and genetic in its origins,” Dr. King says.
What are the symptoms of OCD in a child?
Behaviors that may suggest that a child has OCD include:
- Fear of dirt, germs and contamination from people; fear of touching surfaces
- Doubts about household safety, including, for example, whether or not a door is locked, a window is shut or appliances have been turned off
- Preoccupation with presentation, appearance and organization—for example, the look of homework, or the symmetrical arrangement of objects, clothing or food
- Anxiety about accidentally hurting a parent, sibling or friend
- Superstitions that bad things will happen if seemingly unrelated behaviors are performed or not performed (such as stepping on a crack in the sidewalk or tapping something a certain number of times)
Among the compulsions that a child with OCD may develop are:
- Cleanliness, or a constant need to wash, bathe, shower or change clothing
- Rituals, or a need to move or touch body parts in a certain way or achieve symmetry in movements
- Rigidity about mornings or bedtime
- A need to repeat words or prayers to keep bad things from happening
- Reassurance-seeking from parents, teachers or others
- Avoidance of situations in which the child thinks “something bad” might occur
How is OCD diagnosed in children?
Diagnosing OCD is not always straightforward, Dr. King says. Some children are secretive about their behaviors, so parents may notice that bedtime rituals have become very prolonged or that, suddenly, there is a lot of extra laundry because a child is showering or changing clothes so often. Also, as OCD often co-occurs with other mental health disorders, such as autism or Tourette’s, “A lot of our work is sorting out what is OCD and what’s related to other conditions,” says Dr. King.
At the Child Study Center, trained therapists offer assessments for OCD that include extensive interviews with parents and the child—to learn about their experiences and build a rapport—and structured measurement questionnaires.
“It’s a stressful business for parents to bring their child to a stranger with a puzzling sort of worry,” Dr. King says. “A child may be embarrassed, ashamed, or worried they will be thought badly of. So one of the things that we do is to reassure kids and their families that we see a lot of children and families with these disorders.”
How is OCD treated?
At the Child Study Center, our treatment of OCD is highly individualized. We initially focus on helping families understand what is going on. One area to look at is stress. “We’re very attentive to whether a child is in the right school environment,” Dr. King says, “whether their school and social life is a good fit for who they are, and for their strengths and vulnerabilities.”
Treatment typically includes habit reversal therapy. Developed at the Child Study Center, this evidence-based treatment involves helping children gain awareness of what causes their behaviors, understanding what makes them worse, and learning to substitute other, less intrusive ones.
Some children with OCD benefit from medication. “We have lots of experience with a variety of medications; we have actually pioneered their use over the last 40 years," Dr. King says.
What makes Yale Medicine's approach to OCD in children unique?
The Tic Disorder & Obsessive Compulsive Disorder Program is a leader in research and treatment for those disorders. Several cutting-edge therapies were developed and given pilot programs by the Child Study Center specialists. “I think that our understanding of the disorder helps kids and their parents feel less isolated,” Dr. King says. “We spend a lot of time thinking about kids—not just as the bearer of a diagnostic label, but as full people with strengths and passions and interests and friends and family. We help children make the most use and enjoyment of what they have.”
Dr. King says that every patient benefits from the center’s extensive experience treating a wide range of patients. “We see young children who come straight from their pediatrician, and then we see other very complicated cases,” he says. “We have a lot of experience sorting through the complexities of treatments with kids who have been seen by multiple specialists and have tried multiple medications.”
Additionally, Yale Medicine offers a unique blend of experience and innovation. “It’s a funny paradox,” Dr. King says. “Experience counts, though our younger colleagues—our medical students or residents or trainees—have the most curious minds and the brightest ideas about new things to try.”
“One of the great things about being at Yale,” continues Dr. King, “is that one can draw on such a multidisciplinary group of colleagues, everything from genetics through immunologists through bacteriologists through epidemiologists and psychologists. It’s a wonderfully rich environment. It’s kind of the dream team.”