Obsessive Compulsive Disorder and Teens – The Untreated Diagnosis

Dr. Karen Explains . . .

In my 18 years’ experience as a family therapist, obsessive compulsive behaviors have become a way of life for many teens, have become a less observable diagnosis, and are too often left untreated until they are severe. It is imperative that a teen that has obsessive compulsive disorder (OCD) is treated by a mental health professional, as research on this disorder has shown that it does not typically go away on its own. OCD is a type of anxiety disorder and is web-like in that it invades most if not all areas of the teen’s life, significantly impacting his life experiences.

Parents often brush off their teen’s superstitious impulses that, to a trained professional, are recognizable as OCD. It is quite hard for a parent to know if their child’s behavior is actually classified as OCD or just a quirky character trait. It is also difficult for many parents to distinguish typical anxiety and behaviors that are normal from OCD behaviors that are abnormal and interfere with their child’s functioning, especially since teens typically try to cope with this disorder on their own and don’t realize that they can get help for it.

Parents may think their child’s traits such as being neat, orderly, and extremely concerned about achievement or germs are good qualities—not obsessive ones—and in many cases, these parents are right that their teen does not have OCD. Extreme neatness, organization or conscientiousness about germs do not always indicate a child has OCD, and a child that experiences anxiety and worry or experiences some superstitious tendencies doesn’t mean she has OCD.

OCD symptoms are often left unnoticed as recognizable problems, or are noticed as problems that parents do not believe need treatment because, they rationalize, they are just a part of their child’s character.

Commonly, a parent may view her child’s undiagnosed traits from any of the following perspectives:

• My teen has always been a worrier, so this is just who she is.
• Some people may think my teen’s extreme concerns are negative but I believe they are positive (e.g., child’s concerns about drug use, fears associated with religion, severe travel anxiety) because they show she is a moral person or will keep her safe because she is cautious and makes smart choices.
• I recognize my teen demonstrates repetitive behaviors at times—like re-tying her shoes, or putting on her clothes and then re-doing some aspect of her wardrobe, although it takes her longer to get ready—but she always manages to get ready on time so I do not consider them a problem because her behaviors do not interfere with her getting to where she needs to go.

In essence, parents usually consider their child’s OCD symptoms are normal, and in some families the behaviors are even commended as a strive for excellence.

Some parents don’t recognize their teen’s behaviors as OCD symptoms because their child may have ritualistic and excessive thoughts that aren’t outwardly expressed. Teens may not mention their obsessive thoughts or, if they do, then their parents may just think “it’s a phase.”

One can see how it is hard for parents to definitely know if their child has OCD, but a trained professional can quickly recognize the symptoms. OCD is not just one, two, three or even four examples of behaviors based on fear; OCD is a pattern of mental and behavioral rituals that the child engages in to try to prevent a fear he has and alleviate the discomfort and pain he feels associated with the disturbing thoughts.

By the time parents realize that their adolescent’s behaviors and/or thoughts have crossed the line from normal worry to “full-force OCD” the teen’s mental and behavioral rituals to combat these thoughts are a part of, and have invaded most if not all areas of, her life. Parents may not think their teen’s thoughts or behaviors interfere with her life because she still participates in activities, has friends and is successful in school. In actuality, their child’s thoughts and behaviors completely interfere but she has adapted and seemingly successfully incorporated her mental and behavioral rituals into her daily existence.

A teen with OCD typically not only experiences OCD symptoms at home, but also usually in all areas of his life (e.g., classroom, studying, walking home from school, social interactions, extracurricular activities, getting dressed). For example, when a teacher assigns a writing assignment and the teen is in the middle of writing a sentence, the teen’s inner obsessive voice states a distressing thought that may go away if the teen performs a compulsive mental or behavioral ritual. In this case, the teen may feel if she erases the sentence she was already working on and then re-writes it, then what her voice told her will not come true. Later, when the teen brings home her assignment and her father sees many eraser marks, he may think his daughter is just trying to be a perfectionist and is worried about doing a good job. So, he may feel proud of his daughter for working so hard. In actuality, her behavior is an example of the teen trying to manage the disorder on her own.

Perhaps this teen does not have OCD and really is just trying to do her best in school. How can parents find out if their child is suffering daily where bad thoughts interfere with her existence and where she consistently creates behaviors and thoughts to fight the fear? They should talk with their child.

The only way to really know is to talk with your teen about your observations and ask if she notices what you have noticed. Read about OCD to educate yourself so you can intelligently communicate with your teen and figure out together if she may be experiencing OCD. Mention you read this article and ask her if she thinks she has thoughts that bad things are going to happen that lead her to take action in her mind and/or with her behaviors to prevent the bad thought from coming true. Ask your teen what she specifically thinks or worries about, how she feels about these thoughts, and what she experiences with her behaviors. If you speak in a manner that is interested, loving and compassionate, and that is non-judgmental, then your teen that suffers from OCD will be interested in understanding her diagnosis and will more likely be open to treatment options.

Often when parents notice some symptoms but they are not sure what the problem is, instead of confronting their teen, they go to the doctor’s office, typically the pediatrician. Some pediatricians suggest that if the OCD does not seem to interfere with the teen’s life, then leave it alone so as to not make a big deal out of it. It is important to note that the parents’ description of their child’s observations is typically understated, so the pediatrician doesn’t know the true extent of the symptoms.

However, once parents start to believe their child’s behavior is a problem that needs intervention, it is because it has progressed from mild to moderate to severe. Every time a child “gives in” to OCD, either through behavior or rumination that leads her to create a statement to make the “voice” stop saying what it is saying, it makes the OCD stronger. OCD is a serious problem and the earlier a child receives help the better, as she can learn strategies and new ways of thinking to break the pattern of responding to OCD with mental and/or behavioral rituals.

OCD can be managed and treated with the proper help. Cognitive behavioral therapy (CBT) is the most highly recommended and typical method of treatment. When a child meets with a therapist that is skilled in knowing what to ask, and there is a good rapport, very quickly the therapist can determine that the child has OCD. It is important to have a therapist that the child feels comfortable and safe to work with, as the journey of managing OCD takes time.

Some children do end up needing both CBT and medication, but I strongly recommend cognitive therapy before jumping for the “quick fix” of prescribing a pill. Medication for OCD is not magic; it is not a quick fix that makes OCD go away forever. Medicine can help to take the edge off so that the child can attend to and implement the strategies learned in therapy, but remember, the child still needs coping strategies and effective self-talk methods to help manage OCD. One’s cognitions and behaviors need to change and that is through therapeutic intervention.

If you think your teen has OCD, then my recommendation is not to wait and see if it gets better on its own. Talk with your child about your observations and ask him about his. Research and learn more about OCD. Talk with a therapist that understands OCD and explore how that therapist can help. The earlier OCD is diagnosed and the child is armed with skills to combat it, the better. The psychotherapist or psychologist can help in many ways. He can help your child understand what OCD is and why he performs the rituals. He can educate your teen that the mental and behavioral acts aimed at easing his anxiety about the fear coming true makes the OCD voice become stronger. He can also help your teen take concrete cognitive and behavioral steps to manage and treat symptoms. The therapist may also role-play with your child in the office to practice what to do in certain situations. I have found that many teens find this style of therapy inclusion quite helpful.

From my experience, cognitive behavioral therapy—where the child and therapist play an active role in treatment and tailor the interventions to the teen’s personality—is the most successful method in treating OCD. Supportive, patient and loving parents that are a part of the therapeutic process are a significant part of the teen’s journey.

This article written by Dr. Karen Ruskin appeared in Pediatrics for Parents: Vol. 27, Issues 1 & 2, January/February 2011.