Children who live with Obsessive Compulsive Disorder (OCD) struggle with either obsessions or compulsions, or both. Obsessions are unwanted and intrusive thoughts, images or impulses and make one feel upset and anxious. Compulsions are actions or rituals one is driven to perform to get rid of anxiety. This article explains OCD in children and the effective treatments for helping kids who develop it.
To understand how OCD works, think about a mosquito bite. When you get bitten by a mosquito, it itches, and to make it feel better, you scratch. While you scratch the bite, it feels great, but as soon as you stop scratching, the itching gets worse. That’s how OCD plays out. When a child with OCD feels anxious, they’ll do something to fix it temporarily but that ritual makes it worse over time. OCD often first develops around the age of six to nine.
Young children experience the disorder differently than adolescents and adults do. A young child may not recognise that his thoughts and fears are exaggerated or unrealistic and may not be fully aware of why they feel compelled to perform a ritual; they just know that it gives them a “just right” feeling, at least momentarily. In either case, a child with OCD will respond to their anxiety in a way that is rigid and rule-bound, and interferes with their normal functioning.
The kinds of obsessions that children with OCD are generally preoccupied with can be categorised below.
- Contamination: Kids with this obsession are sometimes called “germophobes.” However, sometimes children may also show disgust towards certain stimuli, for instance, bodily secretions. These kids worry about other people sneezing and coughing, touching things that might be dirty, checking expiration dates or getting sick. This is the most common obsession in children.
- Magical thinking: Magical thinking is an OCD subtype characterised by ongoing intrusive thoughts and compulsive behaviours around superstition or magical thinking to prevent negative experiences or harm to oneself or others. For example, kids might worry that their thoughts are causing someone to get hurt or sick. A child might think, “Unless my things are lined up in a certain way, mom will get in a car accident.”
- Scrupulosity: This is when kids have obsessive worries about offending God or being blasphemous in some way.
- Aggressive obsessions: Kids may be plagued by a lot of different kinds of thoughts about bad things they could do. “What if I hurt someone? What if I stab someone?”
- The “just right” feeling: Some kids feel they need to keep doing something until they get the “right feeling”, though they may not know why it feels right. So they might think: “I’ll line these things up until it just kind of feels right, and then I’ll stop.”
Compulsions can be things that kids actively do — like line up objects, wash hands or things done mentally, like counting in their head. A compulsion could also be an avoidance of something, like a child who avoids touching knives, even flimsy plastic ones, because she’s afraid of hurting someone. Because compulsions are things that parents might notice, it is common for parents to be more aware of them than obsessions.
The kinds of OCD compulsions that children perform to reduce the velocity of obsessions accompanied by anxiety are briefly highlighted below.
Parents might notice signs such as:
- Repeated hand washing, locking and relocking doors or touching things in a certain order by children.
- Extreme or exaggerated fears of contamination, family members being hurt or harmed or doing harm themselves.
- Use of magical thinking, such as, “If I touch everything in the room, mom won’t be killed in a car accident.”
- Repeatedly seeking assurances about the future.
- Repeatedly confessing “bad thoughts” such as thoughts that are mean (thinking a family friend is ugly), sexual (imagining a classmate naked) or violent (thinking about killing someone).
Treatment For OCD
Cognitive Behavioural Therapy (CBT)
The first step in treatment is helping children understand how OCD works. It often helps to put OCD in a context that children can understand. For example, a therapist might explain that OCD functions like a bully. If a bully asks for your lunch money and you give in because you’re afraid, then the bully will be happy and go away.
But the next day, the bully will come back again for more, because they know you are afraid. The more you give in to a bully, the more they will come at you and ask. OCD functions the same way. The goal of treatment is to help a child learn how to stand up to his bully.
The gold-standard treatment for OCD is a kind of cognitive-behavioural therapy called Exposure and Response Prevention, or ERP. ERP works by helping children face the things that trigger their anxiety in structured, incremental steps and in a safe environment. This allows children to experience anxiety and distress without resorting to compulsions, with the support of the therapist. Through facing their triggers, children learn to tolerate their anxiety and, over time, discover that their anxiety has actually decreased.
For example, a child with fears about germs and contamination would create a “fear hierarchy” with their therapist. They would work together to identify all of the contamination situations they fear, rate them on a scale of 0-10, and then tackle them one at a time until their fear subsides. The child would start with a low-level trigger such as touching clean towels and build to more difficult triggers like holding something from the trash.
Your therapist should provide ERP in real-world locations where your child experiences anxiety and make sure that caregivers know how to reinforce ERP skills outside of treatment, too.
Working With Parents
Parents spend the most time with their children, so it is essential for the family to be involved in treatment. You should expect your child’s therapist to work closely with you, explain how treatment works, and give you and your child homework to practice the skills your child is learning in therapy.
Because children often come to parents looking for reassurance or to help with an obsession or compulsion, it is also important for parents to learn the best way to respond to their child without reinforcing their OCD. When a parent gives reassurance, it makes the child feel better in the moment, but that relief is fleeting and can actually reinforce the child’s anxiety in the long run. It also doesn’t help her learn any coping skills to help herself.
Your child’s therapist should work with you on finding ways to respond to requests for reassurance that are supportive without reinforcing OCD symptoms.
Medication Treatment For OCD
While the primary treatment for OCD is CBT, children with more severe cases are often treated with a combination of CBT and medication. A class of antidepressant medication called selective serotonin reuptake inhibitors can be used alongside CBT to help reduce a child’s anxiety, which in turn allows the child to be more responsive to therapy. Medication can be decreased or discontinued as the child learns skills to help her overcome her anxiety on her own.
This article shall not be viewed as an alternative to treatment or consultation for OCD.
About the author: Tanveer Wani is a mental health professional and an alumnus of the National Institute of Mental Health and Neurosciences, Bengaluru. He can be reached at tanveer.nimhans@gmail.com.