What symptoms might parents notice in their child who is exhibiting obsessive -- compulsive disorder OCD )?

Obsessive-compulsive disorder (OCD) doesn't just affect adults; in fact, between 0.25% and 4% of children develop OCD. The average age of onset of childhood OCD is approximately 10 years old, although children as young as 5 can be diagnosed. In rare cases, children show symptoms around age 3.

The similarities between adult-onset and childhood-onset OCD are many, but there are important differences, too. If you are concerned about your child's behavior, knowing the signs of OCD in children may help.

OCD is a mental health condition characterized by obsessions and compulsions that interfere with daily life.

Obsessions

• Thoughts, images, or ideas that won't go away, are unwanted, and are extremely distressing or worrying

Compulsions

• Behaviors that the child feels they must do repeatedly to relieve anxiety

OCD was formerly classified as an anxiety disorder because the obsessive thoughts characteristic of the condition can lead to severe anxiety. The compulsions or rituals performed are typically an attempt to reduce this anxiety. However, the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) moved OCD to its own class of "Obsessive-Compulsive and Related Disorders."

OCD is said to be childhood-onset if obsessions and compulsions occur before puberty. Interestingly, although childhood OCD more commonly affects boys, this trend reverses after puberty. Likewise, boys with childhood-onset OCD appear to be at greater risk for related conditions, including tic disorders.

Children with OCD often have less insight into their obsessions than adults and lack the capacity to understand the irrationality of their thoughts. This, combined with limited and/or developing verbal ability, can make proper diagnosis difficult.

A child’s obsessions and compulsions often differ from those of adults.

• Children with OCD often have specific obsessions related to the death of their parents.
• Children’s obsessions rarely emphasize sexual themes, although adolescents may experience a greater incidence of sexually focused obsessions.
• Children's rituals or compulsions may be more likely to involve or be centered around family members.
• Children with OCD may hoard more frequently than adults with the disorder.
• Childhood-onset OCD also seems to signal a higher risk of tic disorders and attention-deficit/hyperactivity disorder (ADHD).

The signs and symptoms of OCD in children can be categorized as obsessions and compulsions. Common obsessions among children with OCD include:

• Disturbing and unwanted thoughts or images of violent or disturbing things, like harming others
• Extreme worry about bad things happening, doing something wrong, or lying
• Feeling that things have to be “just right”
• Preoccupation with order, symmetry, or exactness
• Worries about getting sick, or getting others sick, or throwing up

Compulsions are often (but not always) related to obsessions. For example, if the child fears germs, they may be compelled to wash their hands repeatedly. Common compulsions among children with OCD include:

• Counting things over and over again
• Elaborate rituals that must be performed exactly the same way each time (i.e. a bedtime ritual)
• Excessive hand washing, showering, or brushing teeth
• Excessively repeating sounds, words, or numbers to oneself
• Ordering or rearranging objects in a particular or symmetrical way
• Repeated checking (such as re-checking that the door is locked, oven is off, or homework is done right)
• Repeatedly seeking reassurance from friends and family

OCD can co-exist with (and also be mistaken for) other disorders that include rigid routines and/or repetitive behaviors or rituals, such as:

Understanding the motivations of a child's behavior is key to a proper diagnosis.

Although the exact causes of OCD in children are unknown, researchers believe several factors play a role, including:

• Brain structure: Imaging studies have found a connection between OCD and abnormalities in the frontal cortex and subcortical structures of the brain.
• Early-life trauma: Some studies have found a link between early-life trauma, such as sexual assault, and symptoms of OCD in prepubescent girls.
• Genetics: Although there's no “OCD gene,” evidence exists for particular versions (alleles) of certain genes that may signal greater vulnerability. What’s more, OCD has been found to run in families: The closer the family member and the younger they were when symptoms started, the higher your risk.
• Stress: Stress from relationship difficulties, problems at school, and illness can be strong triggers for symptoms of OCD in children.

In a recent study, children and adolescents showed a worsening of OCD, anxiety, and depressive symptoms related to the COVID-19 pandemic and associated trauma.

In about 5% of children, OCD is caused by an autoimmune reaction within the brain known as PANDAS or autoimmune subtype. PANDAS OCD is thought to be triggered by infection with the bacteria that causes strep throat and scarlet fever. The child’s immune system becomes confused as it fights the infection and attacks the brain's basal ganglia.

The PANDAS form of OCD has a few key characteristics that help doctors distinguish it from more typical forms of childhood OCD; these include the rapid onset of symptoms. Research has shown that only those children who are genetically predisposed to OCD or tics are vulnerable to developing this form of OCD. The PANDAS form of OCD can require different treatment.

In most cases, the recommended treatment for childhood-onset OCD combines individual or group cognitive behavioral therapy (CBT) with medications that increase levels of serotonin, such as selective serotonin reuptake inhibitors (SSRIs).

Serotonin (also known as 5-hydroxytryptamine or 5-HT) is a neurotransmitter that carries signals between neurons throughout the body. It helps with mood regulation, memory, and other bodily functions. The intestines, not the brain, produce most of the body's serotonin supply.

One of the most popular and effective therapies for OCD is child-modified exposure and response prevention therapy (ERP), a type of cognitive behavioral therapy (CBT). It involves exposing children to the anxiety their obsessions provoke and then preventing the use of rituals to reduce that anxiety. This cycle of exposure and response prevention is repeated until the obsessions and/or compulsions no longer trouble the children.

Both adults and children with OCD frequently ask others to participate in their compulsions. Family members often oblige to reduce their loved one’s anxiety, especially when the person is a child. For treatment to work, compulsions must stop, and family members must be aware of this.

When undertaking CBT with children, parents must be educated and involved. Research suggests that parental involvement is a strong predictor of CBT success.

In severe cases of childhood OCD, treatment may include a combination of CBT and medications such as SSRIs to help reduce a child's anxiety. However, these drugs must be used cautiously in children and adolescents because they can increase the risk of suicide.

Three SSRIs are FDA-approved for use in children and adolescents with OCD:

• Luvox (fluvoxamine): Approved for children age 8 and older
• Prozac (fluoxetine): Approved for children age 8 and older
• Zoloft (sertraline): Approved for children age 6 and older

If OCD is caused by PANDAS, treatment may include the following:

• Antibiotics (penicillin, azithromycin)
• Intravenous immunoglobulin
• NSAIDs and corticosteroids
• Plasma exchange
• Tonsillectomy

Parenting children with OCD can be a challenge, but there are ways to cope. Getting informed about OCD, particularly as experienced by children, is the essential first step that every parent should take to become an effective advocate for their child and family. This can help you reduce your own stress levels and follow through with at-home exposure exercises. Other strategies to try:

• Work on fostering a strong partnership with the professionals involved in your child’s care.
• Don’t be afraid to ask questions and inquire about resources that you can take home to better absorb complex new information in small bits.
• Engage your partner and/or family. If you're having trouble engaging your partner in getting informed or helping with at-home exposure exercises, talk about it. Don't sweep it under the rug. Often, a partner’s reluctance to help reflects their own anxiety about the situation and does not mean they don’t want to help the child.
• Seek support. Look into available resources in your community. A good starting point might be a support group where people share tips for coping with a child who has OCD.

Never give up hope. Although there's no cure for OCD, many effective treatments are available. If the first strategy doesn’t work, keep trying; sometimes, it's simply a matter of finding the right therapist or combination of medication and psychotherapy.

With the proper treatment, many children find relief from their symptoms and learn coping strategies to thrive in daily life. If you think your child may have OCD, talk to your physician as soon as possible.

Frequently Asked Questions

• How common is childhood OCD?

  Between 0.25% and 4% of children develop OCD. Although kids as young as 5 can be diagnosed, the average age of onset is 10. Rarely, OCD occurs in kids even earlier—as young as 3.

• How does OCD change from childhood to adulthood?

  Childhood OCD occurs more often in boys than in girls, whereas the ratio evens out in adults. The symptoms appear gradually and are more severe in early-onset OCD than in late-onset OCD.
  

• What kind of childhood trauma can activate OCD?

  Many forms of trauma can trigger OCD, including infections. However, researchers have found that physical abuse, sexual abuse, neglect, and family disruption were most likely to activate OCD in kids.

• How can you help a child with OCD at home?

  The first, most important step is educating yourself and other family members. It's also important to stay involved with your child's OCD treatment, keep the environment positive and accepting, resist enabling compulsions, and remain open to new treatment options.