The following information is provided to help you, as parents, understand OCD so that you can help your child get the support and services that he or she needs. More specifically, we hope this article will help you begin to know the identifying signs and symptoms of OCD.

What is OCD?
We all desire order in our lives. We all have fears and quirky behavior. We all have little rituals that we do. For example, you may like to be able to plan ahead for a vacation or schedule a workout in your week. You maybe afraid of heights or a specific disease, prefer your scrambled eggs prepared to a certain consistency, like to wear a certain soft white shirt when you go to bed, prefer a certain brand of soap, or put your makeup on in the same order each day. These little rituals and routines are perfectly normal. Usually they just exist because they are useful habits that make life easier. For example, if you put your keys in the same place every night, you'll remember where they are in the morning. This is an efficient little time-saver.

What makes people with OCD different from the rest of us is the amount of time spent engaging in thoughts or behaviors that provide "order," and the amount of distress, anxiety, frustration, and fear that they experience when they are not able to create the "safety" they desire. People with OCD have obsessions. Obsessions are repetitive thoughts or worries that create anxiety. A person with OCD might be obsessed about getting sick, or about others in their family getting sick. They might worry about whether they are doing their work correctly. They might worry about whether their hands are clean. Almost anything can be an obsession if you worry about it enough.

To relieve the anxiety caused by these obsessions, people with OCD also have compulsions. Compulsions are ritualized behaviors that help the person feel better. So, for example, if you were obsessed about getting sick, you might clean your house constantly, washing the walls, counters, and floors over and over to try to make yourself feel safe. Or you might wash your hands many times to try to relieve your anxiety that they were dirty.

These obsessions and compulsions are complicated, and they often seem irrational. A person with OCD might worry about doing "bad things" – that she will do something terrible to someone else. To prevent this, she might become compulsive about everything being "in balance." As a result, she might develop compulsions about balance and order. Every time she touched something with her right hand, she might also touch it with her left. Or every time she bumped into something with her right shoulder, she might also reach over and touch her left shoulder. These little rituals might make her feel less anxious that she was "out of balance" – and therefore more confident that she wasn't about to hurt someone.

How Can I Tell OCD From "Normal" Behavior?
The basic point is that in a person with OCD – or a child with OCD – these obsessions (or anxieties) and compulsions aren't like the little routines that most people build into their day. The following excerpt from Tamar E. Chansky's book, Freeing Your Child From Obsessive Compulsive Disorder, outlines four helpful indicators for assessing the differences between OCD and such normal habits or behaviors:

1) Degree of control over the behavior (Can you walk away from it if you need to?)
2) Degree of distress (Do you derive pleasure or get upset from completing the behavior?)
3) Degree of impairment or interference (Does it get in the way of school, bedtime, family activities?)
4) Time (Do these behaviors take more than an hour a day?)

For most people, although leaving the keys in the same spot every night is helpful, it's not absolutely necessary. If you wanted to you could leave them somewhere else. (This is your "degree of control" – you have control over the behavior.) You also wouldn't get upset if you left the keys somewhere else, or if someone moved the keys. (This is your "degree of distress" – you get satisfaction from leaving them in one spot, but not anxiety if you forget.) Leaving the keys there saves you time, rather than wasting a lot of time. (This is your "degree of impairment." The rituals of a person with OCD take up lots of time, instead of saving time.) And leaving the keys there is a shortcut that takes a few seconds, not a ritual that takes hours to complete. (This is the "time" element – the rituals of people with OCD can take hours.)

Further complicating matters is the fact that OCD symptoms wax and wane, sometimes in patterns that make sense (e.g., they might increase when a child is tired, sick, or experiencing a great deal of change like starting a new school year), and at other times without any pattern or logic. This tendency for symptoms to increase and then decrease over time often makes diagnosing OCD difficult. It also makes dealing with it in the family incredibly stressful. For example, one mother reported that her child with OCD might take twenty minutes to get her socks "just right" on her way to school – constantly taking the socks on and off until they feel right. But when that same child is in a rush to play with a friend, she might be able to throw the socks on and be in the car in twenty seconds. The differences in her child's ability to complete this task often made the mother feel that her "difficulties" on those school days were about control or defiance rather than OCD.

Moreover, sometimes parents are not even aware that their child is engaging in "rituals" and instead may believe that their child has difficulty controlling anger. One dad described his son's habit of screaming, crying, and even hitting his brother for no apparent reason each morning while getting dressed in his room. The father thought that his son acted this way for "attention and control." Later the dad recognized that his son was counting silently to himself while getting dressed, and that his rage was about having his ritual "interrupted" – not about a need for power.

OCD can be hard to spot in kids for another reason: children often do not recognize what is happening. While the DSM IV (the manual used by professionals in diagnosing mental disorders) suggests that most of the time a person with OCD "recognizes the senselessness of their obsessions," this is not always the case with children. Sometimes children can recognize that their "worries" are extreme or senseless, but at other times they may have very little insight. What seems obviously "irrational" to you as a parent may not seem out of the ordinary to your child. Moreover, even when children do recognize some of what is happening for them they may have difficulty communicating it.

For example, a child who stays in the shower for forty-five minutes may not do so because she believes that she is contaminated with germs and will die unless clean. Rather the child may continue to do rituals in the shower because "I just have to." She may not have a good explanation of her rituals. It is also important to understand that even when a child can recognize both an obsession and a compulsion, not all obsessions and compulsions are related in any identifiable way (e.g., lining up stuffed animals in a certain order and turning the light switch off and on seven times may be the compulsion that helps keep the fear/ obsession that mom will die at bay). Others are obviously related (e.g., checking to make sure that the stove is turned off again can be the compulsion that alleviates anxiety created by the obsession that the house might burn down).

Why Do Certain People Develop OCD?
Can I Catch It From My Child?
OCD is not something that you can "catch," and it is not just a mood or phase of a child's growth. OCD is a neuro-biological condition. In other words, the brain of a person with OCD behaves differently than the brains of people without OCD.

Recent advances in technology have provided a great deal of insight into the brain activities of those with OCD. In a "normal" brain the basal ganglia and associated structures (i.e., putamen, caudate nucleus, and amygdala) are primarily involved in initiating and controlling bodily movement, filtering and processing information that helps control thinking and behavior, and controlling fear and rage. The orbital cortex regions of the brain are responsible for helping us make sense of the stimuli that we take in from our environments, i.e., they allow us to check and raise doubts about what we see, hear, and feel. The cingulate gyrus takes in information provided by the orbital cortex about possible danger, turns those signals into anxiety and fear, and then sends messages to the basal ganglia that an action is required to alleviate the threat.

(Photograph found at: http://www.nimh.nih.gov/publicat/ocdsoms.cfm, from Rauch SL, Savage CR, Alpert NM, et al. Probing striatal function in obsessive-compulsive disorder: a PET study of implicit sequence learning. Journal of Neuropsychiatry and Clinical Neuroscience , 1997; 9(4): 568-73.)

In PET (positron emission tomography) scans of people with OCD, structures such as the basal ganglia, orbital cortex, and cingulated gyrus are overactive. From PET scan research, it has been hypothesized that for people with OCD, many more signals from the environment are interpreted as potentially dangerous. This produces fear and anxiety and initiates autonomic behaviors to try and reduce the perceived anxiety. More simply, Dr. Chansky compares obsessive thoughts to "junk mail from the brain." In her analogy, a "non-OCD" brain receives messages or mail and is able to distinguish between junk mail and important documents most of the time. For those with an "OCD brain," both junk mail and important documents are received, but the junk mail comes much more often and is often disguised so that the child cannot distinguish between the two types of mail. The junk messages seem incredibly important, and the child feels that they must be responded to. Thus the child engages in compulsions that promise to protect the child from the warnings contained in the junk mail.

The basal ganglia is also important for another reason: they are receptor sites for serotonin. Serotonin is a neurotransmitter in the brain that is responsible for carrying information between nerve cells. When a person does not have enough serotonin, brain messages are not transmitted properly, i.e., they don't stop. Medications such as the serotonin reuptake inhibitors (SRIs) and selective serotonin reuptake inhibitors (SSRIs) affect serotonin levels in the basal ganglia by helping to ensure that messages in the brain are transmitted more effectively. With the improved message transmission provided by the SRIs/ SSRIs, a reduction in OCD symptoms is often observed, providing evidence that serotonin may be involved in the expression of OCD symptoms.

While it is clear that one cannot catch OCD, research indicates that OCD does have a strong genetic component. Dr. Chansky cites studies that indicate that if one parent has OCD, a child's chance of developing OCD is 2-8% higher, than for a child without a parent with OCD. Other studies hypothesize that the prevalence is actually higher with some estimating that about 30% of patients have a family member with OCD. Children with family members who have Tourrette's or other tic disorders also seem to exhibit a higher incidence of OCD. While there is evidence pointing to a genetic link in OCD, it is important to remember that some children develop OCD without any family history of either OCD or Tourette's Syndrome.

For about 20-30% of children who have OCD, a link has been established between the sudden onset of the disorder and strep throat. For these children it is believed that instead of attacking strep cells, the child's antibodies or immune cells attack the basal ganglia. This special subtype of OCD is called Pediatric Autoimmune Neuropsychiatric Diseases Associated with Strep (PANDAS). While PANDAS should be ruled out when trying to get treatment for your child, it is important to remember that strep does not "cause" OCD. A child must have a predisposition for OCD; the strep will only trigger a first occurrence or recurrence of symptoms. Additionally, while some innovative (and controversial) studies are utilizing preventative antibiotics and plasmapheresis (a process that clears the blood of antibodies) to try and treat PANDAS, it is important to recognize that the treatments that are effective in fighting traditional OCD (CBT and medication) are also effective in treating PANDAS.

While a great deal more research is needed to aid us in our understanding of the causes of OCD, what we do know from existing studies is that treatment with both medication and CBT is highly effective. In fact, PET scan studies show reductions in the activity levels of brains of people with OCD. More specifically, PET scans of patients who have been treated with CBT, medication, or both, show marked decreases in the abnormalities found in pretreatment PET scans, and in some cases disappear entirely.

OCD And Other Disorders
It is also important to recognize that symptoms of OCD often resemble symptoms of other disorders. More specifically, children with OCD often exhibit extreme anxiety when separating from a parent, or around issues related to social interaction or school. Often children diagnosed with anxiety disorders such as Social Phobia and Panic Disorder in fact have OCD. Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Sensory Integration Dysfunction are also common "misdiagnoses." These "misdiagnoses" are often given because many symptoms of OCD manifest in ways that mimic the aforementioned disorders (e.g., angry outbursts can look like defiance or ODD, or clothing needing to be "just right" or refusals to brush one's hair can appear to be related to tactile sensitivity or Sensory Integration Dysfunction). Further complicating matters is the fact that children with OCD often do have more than one disorder. Put differently, children with OCD can have coexisting disorders or "comorbid disorders." The most common comorbid disorders seen in children with OCD are as follows: Tourette's Syndrome and other tic disorders, Mood Disorders (e.g., Major Depression, Dysthymia, Bipolar Disorder), Learning Disabilities (e.g., ADD, ADHD, Nonverbal Learning Disorders), Anxiety Disorders (e.g., Generalized Anxiety Disorder, Separation Anxiety Disorder, Panic Disorder, Social Phobia, Specific Phobia ), and Pervasive Developmental Disorders (e.g., Autism and Asperger's Syndrome).

Conclusions
Clearly, diagnosing OCD is difficult, and not something that you should do without professional help. However, despite the inherent challenges ahead (and perhaps behind you), it is important to remember that you as a parent can be an advocate for your child. The first step is to get educated and informed about OCD. Then you need to find support, both for you and for your child. You do not need to be in this alone. Additionally, you can do a great deal to actively help your child fight OCD. You spend more time with and know your child better than anyone. Various treatments for OCD, especially treatments that utilize Cognitive Behavioral Therapies (CBT) and medication, are highly effective in fighting the OCD "monster."

(For more information on helping your child with OCD, see our article on "Helping My Child With OCD" in the Resource Room.)


Note: This article is not intended to constitute medical advice. If you are concerned that you or someone else has OCD, you should seek the help of a qualified physician or therapist to get a diagnosis and treatment. This article is provided merely as an introduction to OCD. We encourage you to read up on OCD in the many excellent books and resources available.