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OCD: When Rituals and Routines Get in the Way

OCD - Boys Town

By: Rachele Diliberto, Ph.D., Boys Town Nevada Behavioral Health

Many children go through a developmental stage where rituals and routines are part of their everyday life and provide comfort and security. Children may want a certain story read to them every night at bedtime, or they may want to only use a toothbrush with a specific cartoon character. They might even have a favorite bowl for their breakfast cereal, or collect figurines because they believe they will bring good luck. These are normal behaviors for children, and it is often okay for parents to go along with them.

However, when rituals begin to interfere in the home or school, or start to take up too much time, it may be a sign of obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) affects approximately 1 to 2% of children and adolescents, and can significantly impact the life of a child and those involved in his or her care. Children and adolescents with OCD experience unwanted thoughts and images that cause a range of negative emotions, including distress, anxiety, disgust, a sense of incompleteness and fear. In an attempt to reduce or eliminate these thoughts and negative feelings, children with OCD perform repetitive or ritualized behaviors called "compulsions." For example, a child may feel as though he needs to put on his clothes in a certain order or say certain words or phrases before entering a room in order to prevent something bad from happening. In extreme cases, children may perform rituals in an effort to ward off scary thoughts about hurting themselves or others that they have no desire to act on. In many situations, children are embarrassed to tell their parents about their distressing thoughts and routines.

Obsessions vary and are different for every child and adolescent with obsessive-compulsive disorder. Obsessive worries may include fear of contamination (becoming ill, or "not being clean"), where the child deals with this concern by engaging in excessive handwashing or cleaning of household items. These actions can be time-consuming or cause discomfort, such as when children wash their hands so often and for so long that they are late for school or extracurricular activities, or their hands begin to crack and bleed. Although these rituals may be connected to concerns about contamination, they also can stem from a fear of acting on thoughts to harm themselves or others, the need to protect loved ones from harm and the need to excessively seek reassurance or to apologize because the child feels he or she has done something wrong. However, these routines or rituals ultimately worsen the intrusive thoughts and accompanying uncomfortable feelings, creating a cycle that is illustrated below.

OCD Cycle - Boys Town

Determining If Your Child's Behaviors Are Linked to OCD

First, ask yourself:  Are these rituals interfering in my child's life?

When routines and rituals start to interfere with functioning, such as your child feeling unable to complete tests because he or she re-reads the questions or rewrites the responses, or withdrawing from social activities due to concerns about contamination or fear he or she will harm others, it may indicate a problem with obsessive-compulsive disorder.

Some guiding questions to help determine whether your child may be dealing with OCD include:

  • Does my child have unwanted ideas, images or impulses that seem irrational, silly or scary?
  • Does my child engage in daily repetitive rituals?
  • Do these rituals (or routines) get in the way of functioning?
  • Does my child become upset if the rituals (or routines) are interrupted?

Treatment

The treatment option with the most evidence of success for OCD is exposure and response prevention (ERP). This technique helps children confront their unwanted thoughts in small steps, first dealing with the negative feelings that are associated with intrusive thoughts without engaging in compulsions, and then confronting these feelings head-on. Over time, children learn to tolerate their anxiety and understand that thoughts "are just thoughts," with no real danger attached. Therapists work with the child and family to develop a "fear ladder," or "hierarchy," starting with the least stressful trigger for OCD and then working up to the most difficult or anxiety-provoking trigger. Therapists also work directly with caregivers to identify and reduce behaviors that may be accommodating OCD, such as providing reassurance for anxious thoughts or reducing the child's contact with items he or she believes are contaminated.

Medication also may be included in the treatment plan to help children begin to confront their unwanted thoughts and reduce rituals or routines. This can be particularly helpful if a child perceives his or her level of distress as intolerable or too anxiety-provoking as he or she begins to reduce rituals/routines. (I encourage families that are considering medication treatment to discuss potential benefits and side effects/risks with a child psychiatrist before making a decision.)

Consider the following resources for more information and to help locate a treatment provider: