|An Introduction to OCD
by Holly Greenberg
1 in 100 children are thought to suffer from Obsessive Compulsive
Disorder or OCD, making OCD one of the most common childhood psychiatric
disorders. Despite its prevalence, however, OCD is difficult
to diagnose, often goes unrecognized and untreated, or is treated
with therapies that are not effective.
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.
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.
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.
little rituals and routines are perfectly normal.
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
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
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.
prevent this, she might become compulsive about everything being "in
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.
every time she bumped into something with her right shoulder, she
might also reach over and touch her left shoulder.
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?
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
4) Time (Do these behaviors take more than an hour
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.)
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.
is the "time" element – the rituals of people with OCD can
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.
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.
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
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
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
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."
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
Recent advances in technology have
provided a great deal of insight into the brain activities of those
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
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
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
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.
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.