Brief description:

OCD is a neurobiological condition which is characterized by obsessions-- repetitive unwanted thoughts, ideas or images typically about harm (contamination, death of a loved one, violent or sexual thoughts) that intrude in the mind and won't let up and compulsions-repetitive behaviors (washing hands, counting, tapping, checking) to try to ward off perceived risk and harm. Unlike everyday worries, obsessions are experienced as disturbing, bizarre, senseless and counter to the child's sense of himself (a devout child has thoughts about cursing at God; a loving child pictures stabbing his parents) and evoke dread, guilt, and discomfort. Categories of OCD symptoms include: contamination, checking, symmetry, religious scrupulosity, violent or sexual thoughts, fears of loss of essence (changing into someone else), fears about sexual orientation (am I gay?). The thoughts are so disturbing to the child that even though they make no sense (tapping everything four times to prevent harm to one's parents) the child feels compelled to believe the authority of those thoughts and comply with the commands.

Typically, when children are bombarded with bad and uncomfortable thoughts, they begin to blame themselves, I'm bad, I'm weird, I must want something bad to happen since I thought it. Rituals or compulsions such as asking for reassurance, cleaning, praying, re-doing, tapping, counting, making things symmetrical are the characteristic solutions to try to get rid of the feeling of incompleteness or uncertainty. Every time an unpleasant thought comes up, you have to do a compulsion, but overtime compulsions change, become more time consuming, and so repeating a behavior 4 times (checking or praying) turns into 16 or 32. OCD is a greedy disorder. The solution perpetuates the problem. OCD requires more and more time and energy in the form of rituals and obsessing to address questions or concerns that were never valid in the first place, the brain should have filtered them out. That's the glitch of OCD.

Red flags:

• Obsessions and/or compulsions take up more than one hour a day or significantly interfere with a child's home life, school life or social functioning:
• Intrusive thoughts, images, impulses that make no sense and are diametrically opposed to the child's being (loving child pictures stabbing parent; religious child fears that hates God; innocent child believes was sexually involved)
• Repetitive behaviors: excessive washing, checking, redoing, counting, tapping to relieve anxiety
• Interferes with functioning- child late for school, unable to get dressed on time for redoing, unable to complete homework due to erasing, rewriting, rereading
• Child fears that he or she is going crazy because of the strangeness of the thoughts

Treatment focus:

Throw Back the Boot! How can bright, sensible children get sucked into their "sticky OCD thoughts" when they make no sense? How can a child be convinced that he's praying to the devil just because he caught a glimpse of a red sweater at church? Part of the problem for kids is that they have flexible minds and incredible imaginations. Even though their brain has picked up a proverbial boot when it was supposed to be fishing for supper, the child can stretch his thinking to find a context that can turn that boot into a fish somehow. But just because they can imagine it otherwise, it's still a boot and they should throw it back. Kids need to learn how to devalue and dismiss OCD intrusions rather than rewriting the history of their life to accommodate this new idea that they want to kill their parents simply because they spied the bug spray during dinner. So when , for instance, a child is checking over a report, and gets an intrusive thought-are these my words, did I plagiarize?-she can quickly transform a "mighta" into a guilty verdict. Maybe I did want to plagiarize-maybe I only thought that I changed the words. Instead of seeing that thought as a random boot or junk thought and throwing it out- I have no intention of plagiarizing, I don't want to plagiarize, I've worked for hours on this report, why would I have bothered to do all that if I was going to plagiarize, she seeks reassurance and can't hand in her paper. She needs to shut down her imagination department for two minutes while she opens the Window of Logic. The sound bites she needs are: Throw back the boot. Don't collect them. It's not your job! Your brain is sending out the wrong message. Plug into what you know about yourself. Break the rules, don't re-check your work. Hand it in!

Exposure and Ritual Prevention (E/RP):

Once kids have learned about OCD's tricks, they can begin to outsmart them by exposing themselves to the OCD situation (touching a doorknob) and refraining from the usual ritual maneuvers (washing hands, using a tissue, only using their fingertips). Overtime the work of E/RP teaches the brain not to send dire warnings in ordinary situations and the child experiences fewer and fewer intrusive thoughts, and when they do intrude, kids have learned how to devalue their message, boss them back, and handle the situation following their preferences and needs, not OCD's strict rules.