Obsessive-compulsive disorder in children can be difficult to distinguish from developmentally normal behavior. The right questions can be revealing—and the right treatments can work.
DR. STORCH is associate professor in the departments of pediatrics and psychiatry, University of Florida, Gainesville. He has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.
We all recall our childhood days of avoiding stepping on cracks so as not to "break our mother's back" or insisting that our father check under the bed every night to ensure the absence of monsters. Repetitive play, superstitions, and ritualistic games are typical aspects of child development. However, parents and pediatricians alike often face the question of when these behaviors cross the line from normal to worrisome-that is, when they may indicate obsessive-compulsive disorder (OCD).
OCD is characterized by intrusive, troubling thoughts (obsessions) and repetitive, ritualistic behaviors (compulsions).1 These behaviors aim to reduce anxiety typically brought on by obsessional thinking. Patients with OCD experience obsessions or compulsions, or both, that are time consuming (take more than one hour per day), significantly impair functioning, or cause distress.1 Many symptoms of childhood OCD resemble those in adults, but children are not required to view their symptoms as nonsensical to meet diagnostic criteria.2
OCD is believed to be significantly underdiagnosed because of practitioners' lack of familiarity with the symptoms, overshadowing by other disorders (such as disruptive behavior), and the embarrassment many youth feel about their symptoms. Indeed, Jenike has described OCD as a "hidden epidemic."10
As in adults, the clinical presentation of pediatric OCD is heterogeneous. Common obsessions include fears of harm, contamination, religious fears, and need for symmetry. Common compulsions include washing and cleaning, repetition of routines, reassurance seeking, and ordering and arranging.11 Approximately 20% of affected youth have compulsions without obsessions.12,13
Not surprisingly, parents often report that symptoms cause difficulties at school, at home, and in social relationships.14,15 Eighty percent to 92% of parents of children with OCD say that their child has significant problems with academic and family functioning.
Comorbid psychiatric conditions
High rates of comorbid conditions have been documented in pediatric OCD patients.13,16,17 As many as 60% to 74% of children with OCD have at least one comorbid psychiatric illness, and approximately 30% have two or more. Anxiety disorders, attention deficit hyperactivity disorder (ADHD), and tic disorders are the most common, although the exact rates are a matter of debate. Some have suggested modest rates of ADHD and disruptive behaviors (20% and 11% respectively),16,17 whereas others have noted significantly higher rates (48% and 33%).13,18 Rates of major depression and dysthymia have been estimated at approximately 10% to 15%.13,16
Is it normal behavior or OCD?
It is often difficult to differentiate behaviors that fall within the spectrum of normal and those that are problematic. Common childhood rituals and superstitious behavior include checking under the bed before going to sleep, touching walls ritualistically while walking, stepping on sidewalk cracks (or avoiding them), or repetitively asking "Are we there yet?" on family car trips. Many young children also experience developmentally normal fears including fear of strangers, the dark, monsters, or animals.19