Children with OCD experience persistent obsessions and compulsions. Obsessions are recurrent thoughts, images, or urges that are intrusive and distressing. Compulsions are repetitive behaviours that are performed in response to obsessions, and are aimed at preventing negative events. Common types of intrusive thoughts reported by young people include concerns about harming others or themselves, contamination, superstitious ideas about bad luck or karma and religious concerns. Common compulsions include washing or cleaning, checking, repeating rituals, ordering and hoarding or saving. Compulsions sometimes involve other people, such as family members. For example, a child may require a specific verbal response in order to complete a ritual.
Children with OCD perform compulsions following an obsession in order to prevent a feared outcome from occurring. After the compulsion has been carried out, they usually experience an immediate decrease in their level of distress. However, this decrease is typically short lived because doubt or other triggers in the environment can result in further intrusive thoughts. It is not uncommon for children or adolescents to feel the need to perform a ritual five times or more. As a general guideline for making this diagnosis, the compulsions must last more than an hour per day. Typically the obsessions and constant compulsions become highly frustrating and time-consuming for the individual. Avoidance of cues in the environment that trigger intrusive thoughts is common. This often leads to marked life interference and feelings of depression.
For example, one 15 year old girl experienced intrusive thoughts every time she used the toilet. Her intrusive thought was “If I don’t wash my hands thoroughly with soap, I will infect the rest of my family with germs and they will get very sick.” In response to this thought, she would meticulously wash her hands with soap for around five minutes after she used the toilet. As she walked away from the bathroom, she would experience further intrusive thoughts, such as, “I haven’t gotten rid of all the germs yet and could still infect people”. She would then perform more hand washing. This cycle would typically continue for long periods until she felt satisfied that there were no longer any germs on her hands, and her anxiety level would then drop. Over time, her hands became chaffed and sore from the constant washing, further increasing her distress.
While adolescents can generally recognize the unrealistic nature of their thoughts and behaviours, younger children can lack insight. Younger children may be reluctant, or unable, to verbalize the nature of their obsessions due to a limited understanding of their difficulties, language limitations, or embarrassment. In such cases parent reports and behavioural observation of compulsions are a necessary source of information.
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