Understanding Obsessive Compulsive Disorder (OCD) in children: Part 1

OCD is confusing. It can look so different from one kid to the next. Often significant parts of symptoms are kept secret. What I hope to offer in this post is something directed to parents who are trying to understand their child’s behavior and how OCD appears.

Determining an exact diagnosis is not always essential. Sometimes if there is more than one clinician involved you might get more than one diagnosis. Diagnosis just isn’t always a clear process. That being said, there is some relief in just knowing what exactly is wrong. Knowing what it is can help you understand it. Sometimes the wrong diagnosis can have big consequences. For example, recently I know of two kids mistakenly diagnosed with an eating disorder when the actual problem was emetophobia. Also, with OCD a very specific type of treatment is by far the most effective so a somewhat confident diagnosis will point you in the right direction. Other types of anxiety may be more responsive to a wider variety of approaches but OCD responds to CBT, in particular, exposure and response prevention. Medication can be effective as well but I will only be addressing the psychological aspects and interventions.

What I am going to do is start broadly (Part 1) and then get more specific (Part 2). Hopefully, I will get around to writing about the treatment. Just so you know, the specific categories in part 2 are not closely defined or organized in the “official” description and various authors and clinicians may organize them differently. What follows is what makes the most sense to me at the present time.

What is OCD?

OCD is an ANXIETY disorder although there is some debate about some specifics or related problems. For our purpose there is intense anxiety or distress for someone suffering with this. It is easy to get confused or overwhelmed by the symptoms so it is important to understand it is powered by anxiety.

Obsessions

So broadly, what is OCD? Let’s start with the “O”, obsessive. The term means a kid’s brain is stuck thinking about something over and over and over. But is it more than just a stuck thought. A kid feels dominated by the scary thoughts and feelings. Obsess was originally a medieval term for besieging a city! This is one of those occasions when the original meaning of the word really fits. A kid’s brain has been invaded by fearful thoughts and feelings.

One thing that is unique with OCD compared to other worries is that these thoughts are commonly felt to be intrusive and unwanted. Because they are unwanted and highly distressing the person feels compelled to do something about them. It is far too troubling to just ignore. The reason the thoughts are so scary is that they are about something of the greatest personal importance. For example, if a child deeply loves someone the thoughts might be that harm would come to that person. The more important it is the scarier the thought. These thoughts are present every day and persist for a long time. The thoughts are extreme and the imagined consequences terrible. Most adults can tell the thoughts and feelings are extreme and unreasonable but sometimes that is not as clear to kids. It is important to note that obsessions cause and increase anxiety.

Compulsions

Because these thoughts are unwanted, intrusive and scary this leads to fierce attempts to do something to fix it and make it safe. This is where the “C” or compulsive part comes into play. A compulsion is an action (mental or behavioral) a kid might take to fix the problem. You need to know for your child, this doesn’t feel optional; the urge to do something feels nearly irresistible. The emotional force and effort can be stunning. A compulsion can take lots of forms. It can be more mental like trying to ignore, suppress, neutralize or counter act the thoughts, or it can be behavioral action to fix or escape the danger. I will describe the most common kinds of obsessions and compulsion in Part 2.

Even though the actions can seem quite eccentric and purposeless they are not. They are definitely disruptive to the normal flow of life. They aren’t even consistent. For example, if the fear is about a contaminant, one bathroom might be totally scary but another fine. To an observer there is no difference. Most parents get pretty worried that their child will have lots of social backlash because of these compulsions. Please understand that the symptoms are an attempt to get rid of the problem that is causing distress. Your kid isn’t okay with looking weird; they are so distressed they will do just about anything to get safe. Kids with OCD are NOT crazy, broken or destined to weirdness. Underneath these intense and sometime peculiar symptoms is a kid just trying to solve what seems like an enormous problem. While obsessions increase distress, compulsions decrease anxiety (although only temporarily). Knowing that is one way to tell the difference between them.

O + C = Disorder

Okay, so you have intrusive, unwanted and highly distressing thoughts that dominate a kid’s thoughts and feelings plus a nearly irresistible urge to do something to fix the fear and make things safe. For a diagnosis of OCD you have them both. By the way, if you have been researching you may have run into something described as pure “O”. The idea is that the only symptom is the obsession. There is no such thing. There are always compulsions. Sometimes the O seems the most prominent and sometimes the C does but they are always both there.

So a quick summary:

Obsession

• Thinking, imagining, focusing on something highly distressing
• These thoughts intrude and dominate your mind
• They are scary because they threaten something deeply important
• They are present almost always and persist day after day
• The content of the thoughts seem personally catastrophic
• Cause or increase anxiety

Compulsion

• A nearly overwhelming urge to do something about the obsession
• It might be mental like replaying a thought, counting to avoid bad luck, replacing bad thoughts with good thoughts
• It might be behavioral like cleaning, apologizing, touching, or organizing
• To an observer it might look useless or contradictory but there is always the underlying purpose of solving a problem
• Reduces anxiety briefly

In the next post I will describe the various ways this will appear in kids.