In children and teens, OCD may be characterized by an obsession with a fear of germs, illness, lucky and unlucky numbers or a fear of harm coming to loved ones. Children often have checking, touching, counting or washing rituals (such as the hands or shower). OCD is likely to have a drastic impact on school performance because obsessions and compulsions tend to take over. Parents may notice OCD because getting ready routines will likely be much longer and more involved. Parents may notice a higher water bill or chapped and dry skin from over-washing. Some children may ask repetitive questions related to germs or illness and may need an exact answer from a parent to move forward.
Obsessive Compulsive Disorder (OCD) is characterized by intrusive thoughts and compulsive, repetitive physical or mental acts that relieve some of the anxiety surrounding the intrusive thoughts. For example, a fear of germs and contamination may be lessened when a person engages in excessive unnecessary hand washing. OCD used to be considered an anxiety disorder because it is characterized by obsessive thinking that can be conceptualized as worrying. In the current Diagnostic and Statistical Manual (DSM-5), the authors created a separate chapter for Obsessive Compulsive Disorders. However, a number of individuals with OCD may also have an anxiety disorder.
OCD is sometimes confused with Autism Spectrum Disorder (ASD) because of the rigidity and routine. The difference is the significant anxiety about the rigid routine. Children with ASD like structure and routine, but they do not engage in structure and routine to contain symptoms of anxiety. In autism, this behavior is more of a preference. Anxiety Disorders can be differentiated from OCD with a consideration of the compulsions for certain behaviors, such as washing, checking counting or touching.
OCD includes obsessions and compulsions that are time-consuming, cause distress and interfere with daily activities. If your child has to check the oven to be sure it is off each day before you leave for school, this behavior may be obsessive and compulsive, but it is likely not something that causes significant distress and is time consuming. Rather, a child who must count every step he takes from his bedroom in the morning throughout the day in order to “protect the family from harm” is obsessive compulsive in a way that probably interferes with his daily activities.
Children with OCD have worries, images, thoughts, ideas or feelings that bother them. These concerns are the obsessions. They spend a long time each day trying to ease these obsessions with mental or physical compulsions and rituals, such as checking, counting, collecting, or washing. These compulsions often have to be performed repeatedly and in a certain way to keep obsessions at bay. OCD interferes with daily functioning and causes significant distress for children, teens and their families.
Cognitive Behavioral Therapy (CBT) with use of Exposure and Response Prevention. Cognitive Behavioral Therapy is a modality with considerable research to support its effectiveness. CBT can be paired with exposure and response prevention treatments that are slowly introduced in a gradual manner, giving anxiety time to dissipate within the situation. For example, a child with OCD may work to gradually touch something with germs and not wash their hands. The child is going to be slowly and gradually presented with the obsession but be unable to complete the compulsive ritual or thinking pattern. Then, CBT can guide children to understand their obsessions and anxiety, recognize their worry and fears, and develop healthy and appropriate coping strategies. OCD treatment is generally individual therapy, but parents or family members may be involved in some cases to work on exposure and response prevention.
Some goals of CBT include the following:
Improve Coping Skills. CBT often teaches and helps kids identify and practice coping skills, such as deep breathing, relaxation, reading, listening to music, taking a walk, jumping on the trampoline, or talking to a friend. Children learn to stop and identify feelings and use a coping skill or to try an anxiety-producing task with support. They work with a therapist to recognize the antecedents, behaviors, and consequences associated with their thoughts and feelings.
Work to improve self-confidence. CBT focuses on identifying thoughts that lead to certain behaviors and determining whether those thoughts are valid or whether they are cognitive distortions. Children learn to combat negative thoughts and to see actions and experiences not as global and uncontrollable but as singular instances and under a child’s control.
Medication. OCD is thought to be related to serotonin levels in our brain. As OCD can be such a time-consuming and life-altering disorder, it is important to consider the use of psychotropic medication prescribed by a child psychiatrist to help treat these symptoms. Medication alone is not likely to successfully solve the problem, but many children and teens make great gains when medication is combined with CBT treatment using Exposure and Response Prevention.
Many tests and measures may be part of a psychological evaluation to determine whether OCD is a relevant diagnosis and to better understand the contributing factors. This evaluation can be hard with children who are sometimes less able to report on their anxiety directly. Some children are very unaware of their own feelings. Using a mix of parent report, self-report, observation and projective measures is often helpful. When OCD is a concern, ruling out ASD is important because these symptoms can be confusing in children. Administering the ADOS-2 will allow providers to rule out ASD when assessing OCD symptoms.
Projectives. Questions, open-ended sentences, and drawing tasks can allow a child to express his or her emotions and experiences indirectly. Themes can emerge related to worry or rejection, and some insight may be derived from the collection of these measures.
Story Telling. Tests like the Roberts or TAT involve presenting story cards to an individual and having him or her tell a story about the vague card. Again, themes and emotional content are noted as well as support of self and support from others.
Rating Scales. Sometimes it is easier for children to express feelings by answering questions. The Yale-Brown Obsessive Compulsive Scale is an excellent measure for asking children and teens about their obsessions and compulsions. Parents and teachers can also complete questionnaires to provide a sense of how each child appears and performs in different settings. This feedback adds to the data because an evaluation is conducted in one setting that is not natural to the individual.
Play observation. Watching a child play with toys can provide insight into his or her feelings, routines, or rituals by attending to themes introduced by the child.
Observation during testing. Looking for restlessness, shy behavior, giddy laughter, noting negative self-statements, noting affective states of the body that indicate tension or discomfort, body language and noting interactions with examiners can provide insight into anxiety. Looking for dry and chapped hands, watching for rituals or noticing excessive time cleaning up, sanitizing or time spent in the bathroom can be helpful.
Executive functioning and processing speed measures. Often, anxious individuals have diminished performance on tasks. A child tested when anxious may have difficulty with planning, problem solving, attention, and other executive functioning skills. A year later, after treatment, some of these areas may be vastly improved.
WHERE TO GO FOR HELP WITH OCD
A referral for a comprehensive neuropsychological evaluation may be warranted to confirm OCD and to better understand your child’s strengths and weaknesses. This type of assessment includes an evaluation of your child’s cognitive ability, adaptive skills, language skills, social skills, mood and anxiety. Other areas may be evaluated as concerns arise. Referrals may include psychotherapy, group therapy, parent consultations, and an Individualized Educational Plan (IEP) or a Section 504 plan.
Psychotherapy. Psychotherapy occurs in an office with a psychologist or therapist and is often focused on improving emotional awareness, coping skills, and restructuring negative thoughts. The psychotherapy modality that has the most research for treating OCD is cognitive behavioral therapy with exposure and response prevention. Other modalities that may be helpful include modular CBT with exposure and response prevention , play therapy (for young children) and mindfulness, which teaches awareness of emotions, acceptance, relaxation and meditation.
Parent Consult. Parent consultation can follow a CBT or a Family Systems model and can provide guidance to parents on strategies to use to hear and support their child and to help them feel understood. It also may focus on principles of reinforcement and ways to support your child with obsessions and compulsions. Consultation can also focus on the parent’s experience and emotional well-being.
School Services. School-based supports like an IEP or Section 504 plan can help your child receive accommodations and modifications that they may require to access learning in the classroom setting. Taking a comprehensive neuropsychological report to any of these professionals will help them to get an understanding of your child. It will be important to think about how these therapies fit together and about how different skills are being built and addressed to best support your child. OCD can impact school performance and social skills. Individual meetings with the school counselor or school psychologist may provide emotional support, assignment of a peer buddy or mentor at school can help as positive event scheduling, and a lunch bunch or social group may also help build peer support. In order to write a formal plan, your school team will need to find an educational impact of anxious symptoms in some aspect of your child’s education.
It may be easier to obtain support through a Section 504 plan if your child’s grades and test scores are not at all impacted. A 504 Plan requires a medical condition that impacts functioning, but academics and test scores need not be directly impacted. An IEP is a more detailed document that does require clear educational impact of symptoms. In addition to emotional supports goals, an IEP would also address challenges in reading, writing, math or communication. Ask your school about both an IEP and a 504 to determine which plan would best serve your child.
Psychiatrist. Often, children with OCD do take medication prescribed by a psychiatrist. Keep your pediatrician in the loop about your child’s mental health, and request a referral to a child psychiatrist to learn more about the benefits and side effects of medication if your child’s symptoms are not appropriately alleviated in therapy or if the severity of symptoms constitutes a multimodal approach.
OCD is a very serious diagnosis, but it can be treated. Taken together, it is valuable to obtain a diagnosis and to engage in the appropriate therapies as early as is feasible. With these supports in place, it is possible to see improvement in OCD symptoms, through identifications of obsessions and compulsions, work to manage thoughts without compulsive behavior, better coping skills for anxiety, and the potential to live a happy life.
 Chorpita PhD, Bruce (2007) Modular Cognitive Behavioral Therapy for Childhood Anxiety Disorders
 Huebner, D. (2007). What to do when your brain gets stuck: A kid’s guide to overcoming OCD.
 Satlzberg, Barney (2010) Beautiful oops!
 McDonnell, Patrick (2014). A perfectly messed up story.
 McCumbee, Stephie (2014). Priscilla & the perfect storm.
 Peters, Daniel B. (2013). From worrier to warrior: A guide to conquering your fears.
 Frank, Kim (2003). The handbook for helping kids with anxiety & stress.
 Beck, Judith S. & Beck, Aaron T. (1995). Cognitive behavior therapy, 2nd edition: Basics and beyond.