Parents may not always recognize OCD in their child
When people think of obsessive-compulsive disorder (OCD), images come to mind of someone who washes their hands or cleans excessively, checks items over and over, or tries to do things perfectly.
Because this is the common perception, many parents may not recognize the signs that their child may be suffering from this condition. Indeed, OCD can present in many different ways, and some children may not even show any overt compulsive behaviors. OCD is a condition where children have obsessions, which are unwanted, intrusive thoughts that children find distressing and difficult to fight. These obsessions cause the child to experience increased anxiety, leading the child to engage in a compulsion, which is a behavior that then neutralizes the thought and reduces the anxiety.
These fears can include:
- Public restrooms; bodily fluids; exposures to radiation, toxic waste, bleach, or cleaning products; specific people; becoming another person or being contaminated by taking in the essence of another person; public areas, school; becoming ill or causing others to become ill, which can be related to general sickness, contracting HIV, or getting cancer, etc.
- Harm towards self or others
- Inadvertently hurting oneself; purposefully hurting oneself; hurting others by accident; hurting others purposefully; being responsible for larger events such as natural disasters, car accidents, burglaries.
- Touching someone inappropriately; lack of certainty surrounding sexual orientation or gender identity.
- Offending God or other religious figures; being responsible for condemning self or family members; being disobedient; doing the wrong thing.
- Magical thoughts and superstitious beliefs
- Belief in lucky and unlucky numbers or belief that unrelated actions and/or thoughts are connected. For example, If I step on a crack, I may really break my mother’s back.
These behaviors can include:
- Excessive cleaning behaviors
- Grooming, washing, toileting, or showering routines.
- Excessive checking behaviors
- Checking stoves and door locks; checking one’s body that there are no injuries, calling family members to ensure they are safe and/or alive.
- Praying and confessing compulsions
- Perfectionism or just right compulsions
- Re-reading, re-writing, tapping, touching.
- Ordering and arranging objects
- Mental compulsions
- Providing reassurance, undoing actions in their minds, counting, saying mantras.
Symptoms Can Be Challenging to Spot
It is important for parents to understand that having these obsessions does not mean that the child wants to do these things or even completely believes that these thoughts are true. In fact, OCD is an egodystonic disorder, which means that the thoughts and behaviors are in opposite or in conflict with what the child actually believes and wants. It is because these thoughts are so conflictual that the child experiences significant distress, leading to their engagement of compulsions. It is also the embarrassment of having the thoughts and the distress and conflict related to the thoughts that cause many children to hide their symptoms from family members and loved ones.
Due to children’s tendencies to hide their symptoms, they often engage in more subtle compulsions that parents may not readily identify. For example, children may ask for reassurance, which is a type of compulsion, in the following ways:
- Ask parents if they love them or tell their parents they love them with the expectation that parents will respond in kind.
- Text parents to ensure that they are still alive or not harmed.
- Subtly confess by making comments that appear banal. For example, a child may say, “I ate cereal this morning.” where the child is seeking reassurance that it was okay for them to have eaten cereal without permission from parents.
- Ask parents if he or she is going to get sick after touching a “dirty” item.
Further complicating the matter is that many children may engage in mental compulsions, rather than overt compulsions. Mental compulsions are specific thoughts that a child may invoke in order to reduce their anxiety. For example, they may say a prayer or mantra in their mind. They may insert a positive thought to counteract a negative thought. As these compulsions are not observable by others, family members or teachers may mistake this behavior as inattention or distractibility. In fact, it is not uncommon for children with OCD to initially be diagnosed with ADHD.
If you suspect that your child may be suffering from OCD, seek out a professional evaluation from a specialized mental health provider who is able to provide a type of cognitive behavioral therapy treatment called exposure and response prevention (ERP). ERP is a very effective treatment for OCD and is considered the gold standard approach for this condition.
In ERP, children work with a therapist to create a hierarchy, or a fear ladder, based on the feared stimuli. Children score their fears from lowest to highest. For example, a child with contamination fears related to public restrooms may rate “Use a public restroom at school” as very high, and rate “Stand in public restroom without touching anything” as low.
Then, children will work with their therapists to slowly practice exposures by voluntarily exposing themselves to the feared stimuli such as anxiety provoking thoughts, images, or environment.
They then engage in response prevention, refraining from engaging in the compulsion. For example, they could work to stand in a public restroom without washing hands afterwards. These ERP practices will start from items that are low on the hierarchy and gradually move up to more difficult items.
Importance of the Family’s Role
Family involvement is integral to OCD. Up to 90% of family members engage some form of family accommodation. Family accommodation is when family members may inadvertently enable the OCD behaviors by facilitating or participating in the OCD rituals. It is important for therapists to work with families to identify how parents and others may accommodate the child’s OCD symptoms and target those behaviors directly.
When family members are involved in treatment, they can learn more adaptive ways to respond to the child’s OCD symptoms and encourage ERP practices. Furthermore, parents can become coaches to their child, learning alongside them how to appropriately complete ERP practices and motivate their children to continue to fight and resist their OCD symptoms. Indeed, family accommodation is associated with higher OCD severity and poorer treatment responses, which means it’s even more important to include family in treatment.
Jennifer Park, PhD, is a licensed clinical psychologist and serves as the Clinical Director of Rogers Behavioral Health’s San Francisco East Bay location and is an adjunct faculty member at Stanford University School of Medicine. Dr. Park is an expert in cognitive behavioral therapy (CBT) and the treatment of children and adults with Obsessive-Compulsive Disorder (OCD), Obsessive-Compulsive Spectrum Disorders, and anxiety disorders. She received individual research funding from Harvard Medical School and has also collaborated on various National Institutes of Health funded research projects. Dr. Park graduated from Amherst College with a Bachelor of Arts in psychology and received her PhD in clinical psychology at the University of South Florida.