It can be emotionally draining to watch your child plan their day around OCD’s demands. You try to alleviate your child’s stress, and you inadvertently collude with your child’s anxiety. You, now, are also a victim to their OCD rules. You may be wondering how you got here, and how to get out. Dr. Courtney DeAngelis, a child psychologist at Columbia University offers expert advice about the childhood OCD cycle, a family’s role in maintaining it, and treatments that work.
The Childhood OCD Cycle
Obsessive Compulsive Disorder (OCD) is characterized by unwanted, intrusive thoughts (obsessions) and physical or mental behaviors carried out to ease the discomfort of those thoughts (compulsions). Those who suffer from childhood OCD often get trapped in a cycle.
This loop starts when a child experiences an obsession, which creates anxiety. The child then gives into an urge to act out a compulsion, which generates a feeling of immediate relief. Children learn that listening to OCD “works”—the compulsion has alleviated their feeling of discomfort. The problem, however, is that the relief is fleeting—a new intrusive thought is likely to show up again that day. The child learns very quickly, and has that learning repeatedly reinforced, that compulsions are either the only way to get rid of these uncomfortable feelings, or that the compulsions “prevent something bad from happening.”
How OCD in Childhood Manifests
Television and movies often depict characters living with childhood OCD as being panicked by germs. And yet, obsessions can manifest in many ways, including intense worry about religion or morality, health, harm happening to self or others, superstitions, and more. Compulsions can also vary between children with OCD, ranging from checking behaviors to cleaning rituals, counting compulsions to rituals that involve parents or family.
Simply put, OCD is like a “brain hiccup.” People with and without OCD can experience intrusive thoughts that pop up out of the blue. Those without OCD may react by thinking, “Huh, that was weird,” and continue to go about their day. Children and teens with OCD might respond with questions or judgments about the intrusive thought: “Why did I just think about that? That’s a bad thing to think. Does that mean a part of me really wants to do that? Am I a bad kid?” Those judgments and doubts create the anxiety that often drives the urge to complete compulsions.
How to Detect OCD in Childhood Routines
Most adults can think of one of their “quirks” that doesn’t make a ton of sense logically. For instance, you might hit the lock button on your remote key four times, even though you’ve already watched your car headlights signal that the door has been locked. Or you might occasionally change your television volume setting to avoid leaving it at your unlucky number.
With children, we often encourage the use of routines to create a sense of predictability and security. Remember when you had approximately 17 steps in your toddler’s nighttime routine that you needed to follow exactly in order to get them to sleep? It might have been quirky, but it worked.
A parent can wonder if it’s really a problem that their child likes to leave the house at an exact time, or if they still have a particular routine at bed. Try to take notice, however, of how much time your child seems to be preoccupied by their worries and spends on their rituals. If you are at or over the one-hour mark—or the thoughts or behaviors are beginning to cause problems—you might want to reach out to a licensed therapist for more help.
Both children with OCD and parents often share that these experiences impact their daily life in some way. A teen might spend hours in the bathroom throughout the course of a day because of an intense anxiety about handwashing. A young child may avoid birthday parties, sleepovers, and playdates in fear that something outside of the house will make them sick.
Some children and teens are better able to conceal their compulsions, engaging in mental rituals that are not obvious to parents, and you might be superhuman in some aspects of your parenting abilities, but you are not expected to catch these invisible symptoms. If your parenting gut says that something is off, it’s probably worth it to seek the expert opinion of a licensed therapist.
Family Accommodations for OCD in Childhood
Parents typically have the best intentions when trying to help their child with OCD. More often than not, however, I ask parents to stop providing the support they have been offering their child.
Participating in a child’s multi-step nighttime ritual, repeatedly answering “OCD questions” to reassure a child that nothing bad will happen, or buying certain household items reserved for the child or that meet the child’s standards of cleanliness only maintain the OCD.
Sometimes OCD can be a “disorder of abundance.” Your teen might not make as much effort to disrupt cleaning compulsions if they believe your home has a never-ending supply of paper towels. Many children and teens are unlikely to feel motivated to change their patterns on their own. This is especially true if you help them, via your accommodations, to rationalize that their OCD doesn't cause problems in the home.
While you might notice more “problems” when you decide not to participate in some of these compulsions, that doesn’t mean you are doing the wrong thing as a parent. In fact, it actually means you’re breaking away from the cycle of OCD. The summary: sometimes things feel worse before they feel better.
How to Treat Childhood OCD Effectively
It’s a hard sell to convince a child who has been actively avoiding something stressful to suddenly agree to engage in that stressful thing. Facing their fears, however, is one of the major principles of exposure and response prevention (ERP)—an effective treatment for OCD in childhood.
When you are living with OCD, or your child is, and first learn about ERP, it might sound like torture. To parents or caregivers, it may sound almost unethical. I assure all kids, teens, and parents that I am not in the business of torturing anyone. I am, however, in the business of educating families on strategies that help give your child time back to activities that are meaningful and important to them.
The good news is that research shows that ERP can significantly improve OCD symptoms. In ERP therapy, your child will learn strategies to cope with anxiety, and to disrupt the OCD cycle. Your child will likely be asked to create an exposure hierarchy or a “brave challenges ladder.” They will collaborate with their therapist to come up with ideas of activities that require them to face their fears, all while resisting the urge to give into a compulsion. The therapist will guide your child to gradually tackle ideas on this list, helping to essentially rewire the brain, seeing that intrusive thoughts are just words floating around in their head, and that compulsions do not have any true ability to protect them.
I remember supporting a teen with worries that they could be responsible if something bad happened to someone else, just by thinking about the bad thing. I wrote on a post-it note, “I hope that my husband gets a flat tire.” I did this as an experiment to test out the teen’s belief that saying or thinking something can make it come true. I told this teen that I would not throw it away, nor say or do anything to try and “take it back” or undo the exposure—my brave challenge. I kept my word and left the note on my desk for a week. When I saw the teen in our next session, I proudly reported that all of the vehicle’s tires were round and fully functional.
I kept that post-it on my desk beyond the week to test it out with other patients. Eventually, months later, my husband did get a flat tire. I can assure you that I did not give in to any fleeting doubt that my post-it was responsible for this inconvenience in his day. I did have evidence, though, to help me trust that I do not have any magical abilities to manifest positive or negative outcomes just yet—and so I created another post-it that read “I will win the lottery.” That one has yet to come true. I may give that one some more time, however, just in case.
If your loved one struggles with childhood OCD, consider reaching out to a licensed therapist today who can help set an appropriate treatment plan. Handspring Health provides expert, collaborative, and flexible care backed by clinical evidence that is tailored to your child’s needs.