Obsessive Compulsive Disorder (OCD) is a mental health disorder that frequently presents in childhood, and, like many pediatric mental health issues, is misunderstood, underreported, and misdiagnosed. In children, it may be particularly easy to dismiss the hallmark behaviors of OCD as the stubbornness or intensity of a dramatic toddler.

But OCD is a mental health disorder, and can be treated and mitigated effectively with appropriate cognitive or behaviorial therapy, and sometimes with medication.

What is OCD in Kids?

OCD is a combination of obsessive thoughts and the compulsive behaviors intended to remedy or ameliorate those thoughts; it becomes so intensive that it disrupts the child’s normal functioning.

Obsessions are recurrent and persistent thoughts, images, or impulses that are intrusive and create feelings of fear, doubt, or disgust. For example:

• Worrying about germs, getting sick, or dying.
• Extreme fears about bad things happening or doing something wrong.
• Feeling that things have to be “just right.”
• Disturbing and unwanted thoughts or images about hurting others.
• Disturbing and unwanted thoughts or images of a sexual nature.

In trying to neutralize the impact of these excessive thoughts, people with OCD start performing repetitive, compulsive actions to respond to the obsession. Common compulsions include:

• Excessive checking (re-checking that the door is locked, that the oven is off).
• Excessive washing andor cleaning.
• Repeating actions until they are “just right” or starting things over again.
• Ordering or arranging things.
• Mental compulsions (excessive praying, mental reviewing).
• Frequent confessing or apologizing.
• Saying lucky words or numbers.
• Excessive reassurance seeking (e.g., always asking, “Are you sure I’m going to be okay?”).

Because compulsions exist to mitigate the anxiety produced by obsessive thoughts, if anything interferes with the compulsive behavior, a child with OCD will experience heightened anxiety or fear, and will likely lash out.

The incidence in the pediatric population is as high as 2-3%.

What’s the difference between OCD and “normal” stubbornness in children?

Toddlers and young children can be exasperating to parents when they exhibit seemingly irrational impulses to repeat certain routines and behaviors. Most children are highly ritualistic. They may want their toys organized a certain way, they may only want to eat one color food, they may insist on bedtime or mealtime rituals that seem irrational to adults, and they may be very upset if these preferences and rituals are disrupted. However, this is entirely age-appropriate and developmentally normal; it is not obsessive compulsive disorder.

(Ritualistic behavior in children appears at approximately 18 months, peaks at approximately 2-3 years, and declines afterward. As a child ages, compulsive behaviors are usually replaced by hobbies or focused interests.)

Normal compulsive behaviors are different from clinical OCD in several ways:

Most importantly, the obsessions and compulsions associated with OCD disrupt the child’s normal functioning. She may not be able to focus on or complete school work, or even attend school on some days. It may inhibit her ability to have normal friendships or play a sport. If the child’s thoughts or compulsive behaviors are interfering with normal daily functions, it is cause for concern.

Furthermore, thoughts or behaviors associated with OCD also differ from the norm in the following ways:

• Frequency – OCD rituals are extremely time consuming and occur with immense frequency;
• Content – the topic of obsession or focal point of the ritual is not a normal part of the daily routine, such as teeth brushing or eating or bedtime;
• Intensity – obsessions and compulsions are intense, and highly upsetting if disrupted.

It is doubly difficult to identify pediatric OCD sometimes because children may not recognize that their obsessive thoughts are not normal, and therefore may not report them to parents.

When parents do report OCD symptoms to healthcare professionals, children sometimes get misdiagnosed with ADHD because of their inability to complete normal daily functions. However, children with OCD have an extreme level of attention to detail and an ability to focus on minute tasks with intense concentration; ironically, these are exactly the things that children with ADHD are unable to do.

If you suspect that your child experiences unmanageable obsessions and seems to engage in compulsions with extreme frequency and intensity, please contact a mental health professional. There are many appropriate treatments to help patients with pediatric OCD.