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Obsessive Compulsive Disorder (OCD) in Children and Youth

Summary: Obsessive Compulsive Disorder (OCD) is a condition marked by having obsessions (distressing thoughts that you can't get off your mind) and/or compulsions (distressing habits, rituals or behaviours that you feel compelled to do over and over again).
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"He just can't stop washing..."

William is an 8-yo boy who enjoys hanging out with his friends and family, and is a great soccer player. But over the past few months, he's been much more concerned about his cleanliness. In the beginning, his parents thought it was great, because he began showering more often. But now he needs to shower several times a day and will actually get upset and angry if he can't have his shower. And in the past few weeks, he's become extremely concerned about germs to the point where he won't even touch door handles. And if he does, he has to wash his hands, and so now it's to the point that his hands are chapped, sore and bleeding from all the washing...

What is Obsessive Compulsive Disorder?

Obsessive compulsive disorder (OCD) is a condition where people have troubles with obsessions and/or compulsions:

  • Obsessions are distressing thoughts or images that won't go away, for example, worries about being dirty or contaminated.
  • Compulsions are behaviours that the person feels forced to do, in order to relieve distress related to the obsession. For example, having to wash one's hands over and over again in order to feel less anxious about being contaminated.

Many people are obsessive or perfectionistic about certain things. Indeed, when we have just enough of these traits, it can be helpful.

 

For example, a person who is obsessive about cleanliness will definitely be better at preventing the spread of germs and infections.

 

But when these habits get so severe that it gets in the way of life, then it becomes a disorder. In OCD, concerns of cleanliness can get so severe that a person may end up:

  • Avoiding touching even family members for fear of contamination
  • Wash his/her hands so excessively that they become chapped and bleeding.
  • Avoid going to school due to fears of contamination
  • Be unable to turn on the TV because others have touched it.
  • Spend hours every day consumed with cleanliness related rituals

Common types of obsessions and compulsions

 

Type

Obsession/Compulsions

Cleanliness / contamination

Worries that things are dirty or contaminated, which leads to a compulsion of needing to wash or bathe over and over again, or avoiding touching things that might be ‘contaminated.'

Symmetry and order

Gets upset or distressed if things aren't exactly ‘just so' or in a certain order. May spend large amounts of time arranging or re-arranging things in one's room, workplace or other places.

Numbers and counting

Having to count or repeat things a certain number of times, having "safe" or "bad" numbers.

Self-Doubt and need for reassurance

Fear of doing wrong or having done wrong, which may lead to repetitively asking others for reassurance, over and over again.

Guilt/need to confess

Needing to tell others about things that s/he has done.

Checking

Excessive checking of such things as doors, lights, locks, windows.

Perfectionism

Excessive time doing things over and over again until they are perfect, or ‘just right'.

 

OCD symptoms can then lead to other problems such as:

  • Troubles paying attention, because the person's attention is focused on obsessions/compulsions
  • Anxiety and anger if OCD routines get interrupted.
  • Lateness and fatigue from energy and time that rituals require
  • Withdrawal from usual activities and friends
  • Trying to get friends and family to cooperate with the OCD rituals.

Even though it might just be your loved one who has OCD, everyone in the family is usually affected by OCD. And hence, everyone has a role to play in helping make things better.

How Common is it?

OCD occurs in about 1-5% of children and youth (American Academy of Child and Adolescent Psychiatry, 1998).

If You Suspect OCD

If you suspect that your child has OCD, have him/her seen by a medical doctor to make sure there aren't any medical problems that might be contributing to the problem.

 

In extremely rare cases, OCD may actually be caused by a type of infection known as streptococcal infection. In these cases, treatments such as antibiotics may be helpful.

 

The doctor may also recommend more specialized mental health services, or help with referrals to mental health professionals such as a psychologist, psychiatrist or social worker.

How is OCD Treated?

The good news is that there are various effective treatments and ways to deal with OCD (American Academy of Child and Adolescent Psychiatry, 1998). The two main types of treatments that can help OCD are:

 

1.     Cognitive behaviour therapy (CBT): a type of therapy  that helps a person with OCD learn new ways to think ("cognitive") and ways to do things ("behavioural") to deal with the OCD. CBT is usually provided by a psychologist or psychiatrist. There are many books on OCD as well, which makes it easier and easier for people with OCD and their families to learn about these strategies and use them on their own (e.g., "Talking Back to OCD" by John March).

 

2.     Medications: specific serotonin reuptake inhibitors (SSRIs) help OCD by affecting the function of the neurotransmitter (chemical found in the brain) serotonin.  Medications can be very helpful in cases where a person has not responded to non-medication treatments.

 

Medication may be needed for a shorter or longer period depending on the person's need.

 

In a very small percentage of cases, OCD is due to a type of bacterial infection known as streptococcus and in those cases antibiotics may be helpful.

Cognitive Behaviour Strategies for OCD

Cognitive behavioural therapy (CBT) is one of the most effective treatments for obsessions or compulsions and uses both cognitive and behavioural techniques (March, 1998).

 

1.     Cognitive Strategies

 

OCD makes a person have OCD thoughts, and cognitive (thought) strategies are about replacing OCD thoughts with more helpful thoughts.

 

For example, a child with cleanliness obsessions touches a school textbook and gets the automatic thought (cognition), "Now I'm all dirty and I'm going to get sick! I have to wash my hands!"

 

Cognitive techniques help the person develop more helpful coping thoughts such as, e.g. "I'm not going to let the OCD push me around! So what if I've just touched the book? I'm not going to get sick. And if I do, well, then maybe I can miss school."

 

2.     Behavioural techniques

 

a)     OCD Hierarchy

 

A hierarchy is a way of deciding which OCD behaviours to work on first. It involves ranking one's compulsions (or obsessions) from those that are easy to resist, to those that are ‘medium' difficulty to resist, to those that are extremely hard to resist doing.

 

b)     Exposure with Response Prevention

 

Exposure  is exposing your child/youth to the (feared) situation that triggers the OCD. For example, if you have a child whose hand washing rituals are triggered by touching "contaminated" objects, then you would expose the child to "contaminated" objects.

 

Response prevention is preventing the response (or ritual) that the OCD tries to boss your child into doing.

 

For example, a child with hand washing compulsions would feel an urge to wash his/her hands after touching "contaminated" objects. Response prevention is where the person agrees to stop doing the compulsion. Although this is anxiety-provoking in the beginning, the more this is done, the easier it becomes over time to stop doing the compulsion.

 

This is where the hierarchy comes in. The hierarchy is used to decide which situations to start working on first.

 

Making a hierarchy is important because when starting to work on OCD compulsions with a therapist, it is usually best to start working on easy or moderately hard compulsions, as opposed to working with the hardest compulsions first.

 

For example, a hierarchy of compulsions might look something like this:

 

  • Easiest: Touching my own things
  • Easier: Using the toilet at home
  • Harder: Touching friend's possessions; Using toilet at friend's home
  • Hardest: Touching things at school; Using toilet at school

Narrative strategies for OCD

Narrative therapy (White, 1990) is a powerful way to deal with problems by talking about them in a certain way. Many therapists will use both narrative and cognitive behavioural strategies in treating OCD in children and youth (March, 1998).

 

Make the OCD the problem, not the person with OCD.  Although OCD symptoms can be very frustrating and cause conflict with families, it is important to remember that it is not the child/youth that is the problem, it is the OCD. A powerful technique from narrative therapy is to talk about the OCD in the third person, in order to help parents join forces with the child, to work together against the OCD.

 

A therapist might say something like:

 

Therapist (or parent):

You know this thing about needing to wash your hands over and over again? That's not you - that's a condition called OCD, and its tricking your brain into making you wash your hands.

What would it be like if OCD weren't around anymore?

Child:

A lot better.

Therapist (or parent):

And that's why we're going to work together, and find ways to keep OCD from bossing you around.

 

Naming the OCD. Although teenagers are usually happy to call the symptoms OCD, younger children often like to give it their own name.

 

Therapist (or parent):

Although we adults call it OCD, it can help if you give it your own name. Any name you want to give it?

Child:

"Germy!" because it makes me think that I have germs all the time.

 

Other examples of names that children/youth call OCD are: "the brain bully", Mr. Meany, Mr. Nag.

 

Agree with the child on the goal, i.e. getting rid of the OCD. When faced with OCD symptoms such as hand washing, a natural response of many adults is to simply try to stop the child from hand washing. But since children and youth may not have the same insight as adults, they may get upset if adults suddenly try stopping them from engaging in the OCD rituals. From the child's perspective, stopping the rituals is going to make them feel more distressed in the short-run. The challenge is for adults to help the child see that things would be better in the long-run.

 

A therapist or parent might say something like this:

 

Therapist:

Okay, so what would it be like if we could help you get rid of Germy?

Child:

A lot better!

Therapist:

Remember what it was like before Germy started bossing you around?

Child

Yeah... I didn't have to wash my hands all the time. And I was able to go to my friend's places.  

Therapist

And that's why we are going to work together, so that we can stop Germy from bossing you around so much. It might be tough in the beginning, but eventually, you'll feel better, and be able to do more fun things again, like going to hang out with your friends again. And your hands will feel so much better.

 

Here is another example of this:

 

Therapist

OCD tries to trick you into thinking your hands are dirty, so that you'll have to wash them. What do you think?"

Child

Yeah... that's what Germy does. I feel so icky and I just have to wash my hands.

Therapist

And after you wash your hands, how do you feel?

Child

Better!

Therapist

What if we could find another way to help you feel better, without having to wash your hands?

Child

That'd be better!

 

Blaming it on the OCD doesn't take away responsibility. Some parents become worried that if we blame the symptoms on the OCD that the child might not take responsibility for dealing with the problem. For example, if a child with OCD gets into a fight and hits his sister because she interrupted him during his rituals, he simply says, "Well, it's not my fault, it's the OCD!"

 

To ensure that responsibility still stays with the child, a therapist (or parent) might say something like this:

  • "You didn't cause your OCD and it's not your fault. It's also not your parent's fault or anyone else's fault."
  • "But it is still your responsibility for getting over the OCD. Like seeing a counsellor. [Or taking medications]. But you're not alone; we are all going to work together to help you deal with this. How's that sound?"

Ask your child how you can support him/her. You might say things such as:

  • "How can we work together against the OCD?"
  • "Is there anything I can do to help you control the OCD, and keep it from controlling you?"

Praise your child for bossing back the OCD. All children need praise, particularly children struggling with OCD. A child struggling with OCD is often hearing a lot of criticism or negative comments from others.

 

You might start with:

  • "How did you do today in bossing back the OCD?"
  • "I'm sure there were some times today where the OCD wasn't as strong, or when you bossed it back. How did you manage to do that? What did you say or do that helped?"

And of course, remember there are many ways to praise a child:

  • "Good job on bossing back the OCD!"
  • "Awesome!"      

Summary 

OCD is a condition where a person experiences obsessions (distressing thoughts or images) and compulsions (habits or rituals that s/he has to do over and over again).

 

Fortunately, there are many effective treatments and strategies for dealing with OCD. 

"William is doing much better now..."

William's parents brought him to see his family doctor, who recommended a psychologist. After seeing the psychologist, William and his parents learned all about cognitive behavioural therapy and ways to ‘boss back' his OCD. His parents learned strategies too, and how to support William in fighting the OCD. Interestingly, William's father realized that he had had minor symptoms of OCD all his life too, and he had just as much benefit from learning about OCD as William did. But back to William - with all the help, his showering and hand washing are almost back to normal... How ironic life is, thought his mother -- who would have thought that one day I'd actually be praising my son for NOT showering!

Readings for Families

Talking Back to OCD, by John March and Christine Benton, 2007.

 

Freeing Your Child From Obsessive-Compulsive Disorder, by Tamar Chansky, 2000.

 

What to do when your child has Obsessive Compulsive Disorder - strategies and solutions by Aureen Pinto Wagner Ph.D

 

Obsessive Compulsive Disorder - New Help for the Family by Herbert L. Gravitz Ph.D

 

Up and Down the Worry Hill by Aureen Pinto Wagner Ph.D.  (Great for young children)   

Websites

The following websites have additional information about OCD:

 

Canadian Mental Health Association

http://www.cmha.ca/bins/content_page.asp?cid=3-94-95

 

American Academy of Child & Adolescent Psychiatry 

http://www.aacap.org/factsfam/ocd.htm

 

MentalHealth.com

http://www.mentalhealth.com/fr20.html

 

Anxiety Disorders Association of America

http://www.adaa.org/aboutanxietydisorders/ocd/index.cfm

 

Obsessive-Compulsive Foundation

http://www.ocfoundation.org

 

American Academy of Family Physicians

http://www.aafp.org/patientinfo/ocd.html

 

Specifically for Children and Youth

References

Practice Parameters on the Assessment and Treatment of OCD. American Academy of Child and Adolescent Psychiatry, 1998.

 

Narrative Means to Therapeutic Ends, by Michael White, 1990.

 

OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual, by John S. March and Karen Mulle, 1998

About this Document

Written by the eMH Team and Partners, along with Janet van den Heuvel of the Parent OCD Support Group, Ottawa.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance. 

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Date Posted: Oct 29, 2008
Date of Last Revision: Oct 8, 2016

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