Given the complex nature of the disorder, OCD is likely multiply determined. Biological models suggest that OCD may result from a dysfunction of the basal ganglia and, more specifically, with cortico-striato-thalamo-cortical circuitry (Saxena & Rauch, 2000). Neurotransmitter theories of OCD suggest that the disorder results from dysregulation of serotonin in the brain; however, this conjecture is based largely on pharmacotherapy studies noting symptom reduction when selective serotonin reuptake inhibitors (SSRIs) are used (Insel et al., 1985; Kalra & Swedo, 2009). To date, there has been little research into the role of serotonin in the pathophysiology of OCD. A recent review of the behavioral genetics literature suggested that OCD is, at least in part, heritable, with 45–65 % of variability accounted for by additive genetic influence (van Grootheest et al., 2005).

Learning theory has been more useful in terms of designing psychosocial treatments for OCD symptoms, since the theory focuses on describing and influencing maintaining factors. Behavioral models of OCD were developed from Mowrer’s seminal work on a two-factor theory of fear and avoidance (Mowrer, 1939, 1960). Specifically, typical thoughts become associated with fear cues via classical conditioning. Individuals subsequently learn that engagement in rituals reduces fear by allowing escape from or avoidance of obsessional thoughts. Thus, OCD symptoms are maintained by negative reinforcement (Shafran, 2005). The momentary reduction in anxiety reinforces continued engagement in rituals (Albano, March, & Piacentini, 1999).

Cognitive-behavioral perspectives suggest that OCD results from either a dysfunction in cognitive processing or that obsessional thinking results from cognitive distortions (Salkovskis, Shafran, Rachman, & Freeston, 1999; Taylor, Abramowitz & McKay, 2007). Some studies suggest that compared to non-sufferers, individuals with OCD show deficits in varied cognitive tasks, with those deficits remaining after successful treatment (Nielen & Den Boer, 2003). With respect to cognitive distortion models, Salkovis posits that individuals with OCD experience intrusive thoughts and appraise them as dangerous, resulting in persistent attempts to suppress them via rituals (Salkovskis, 1996). A cognitive distortion hypothesized to underlie almost every manifestation of OCD is intolerance of uncertainty, or the need to be 100 % certain (Grayson, 2010). For example, a child might spend excessive amounts of time constantly rechecking that all his or hers school supplies are in his or hers backpack before leaving home and making him or her miss the bus. Studies evaluating cognitive-behavioral interventions have provided mostly positive support, with the majority of participants experiencing clinically meaningful reductions in OCD symptoms (Clark, 2004).

Roughly 90 % of children with OCD report significant functional impairment in at least one domain, and nearly half of them report experiencing difficulties in school, at home, and in social relationships. Parents tend to report more dysfunction in home and school than their children do, with the most common complaints being difficulty focusing on schoolwork and doing homework (Piacentini 2008). Level of functional impairment is related to symptom severity and comorbid depression; youngsters with good insight typically show less impairment. Rituals involving contamination or cleaning, aggression, or checking have been associated with greater functional impairment (Storch et al., 2010).

Classroom tasks may prove increasingly difficult as symptoms prevent the child from completing assignments in a timely manner. Ritualistic behaviors may also cause the child to withdraw from social activities due to embarrassment. Among adolescents, rituals may prevent engagement in typical teenage activities, such as dating, work, or driving (Albano, Chorpita, & Barlow, 2003). Teachers may inadvertently reinforce or accommodate rituals, such as providing extra time for tests to relieve the child’s anxiety. While this can be a useful short-term strategy to reduce a child’s distress, it may maintain or exacerbate symptoms over time.

OCD significantly impacts family members and disrupts family routines. Research suggests that family distress appears to be positively correlated with the degree to which family members accommodate a child’s OCD symptoms (Storch et al., 2007). Although parents may perceive the accommodation of rituals as beneficial, the process serves to promote and maintain symptoms. Additionally, accommodation is counterproductive to the treatment process since it presents the child with opportunities to avoid participation in feared activities, thereby validating the child’s fears and apprehension (Merlo, Lehmkuhl, Geffken, & Storch, 2009).

Functional impairment in OCD can be so profound that youngsters who suffer from OCD may need added supports. According to the International OCD Foundation , students may be eligible to receive special education services and accommodations under the Individuals with Disabilities Education Act (IDEA) if symptoms significantly impair functioning within school settings. Psychoeducational assessment and substantiation that previous academic and/or behavioral interventions were ineffective are typically required. It is important to clarify that accommodations provided in academic settings differ from the parent or teacher accommodations discussed earlier as playing a role in maintaining OCD symptoms. For example, an accommodation plan might include an aide helping the child decrease their rituals by coaching them through feared activities or situations.

Obsessions and compulsions differ from normative developmental fears and rituals. A study of 511 children and adolescents indicated a variety of fears are experienced, including worry about daily events and worry about their family’s safety at night (Gordon, King, Gullone, Muris, & Ollendick, 2007). Distinguishing between normal developmental behaviors and maladaptive rituals can be challenging, as ritualistic behaviors among young children are common, particularly around bedtime and mealtime (Evans, Gray, & Leckman, 1999). This may include nighttime rituals with parents, such as being kissed on each cheek in a particular way.

A primary factor that distinguishes OCD behaviors from transient rituals or behavioral preferences is the level of the child’s anxiety if a ritual is interrupted or prevented (Albano, Chorpita, & Barlow, 2003). Further, developmentally normal rituals are typically not as time consuming or impairing and usually end by age 8 or 9 (Geffken, Sajid, & MacNaughton, 2005). For example, an 11-year-old boy who insists on engaging in protracted rituals (e.g., rereading and rewriting homework assignments until everything feels “just right”) is displaying developmentally inappropriate behavior.

OCD often does not occur alone. High rates of comorbidity in childhood OCD are common, and patterns of comorbidity change throughout development. Attention Deficit/Hyperactivity Disorder and tic disorders are commonly comorbid with childhood onset, and depression and anxiety are more frequently comorbid with adolescent onset (Mancebo et al., 2008). There are gender differences, with boys more likely to present with comorbid tic disorders than girls (Swedo et al., 1989), with almost 70 % of children with OCD presenting with tics (Leckman et al., 1997). Lebowitz and colleagues (2012) found that children with comorbid tic disorders and OCD displayed more severe tics than children with tic disorders alone. Additionally, the former group scored higher on measures of psychopathology, including depression, anxiety, and psychosocial stress. Distinguishing complex motor tics (e.g., repeating a particular action until it feels right) from compulsions can be challenging (Lewin, Chang, McCracken, McQueen, & Piacentini, 2010), particularly when rituals are simple, repetitive movements like tapping or stepping in specific ways (Kalra & Swedo, 2009). One difference is that tics typically occur with a premonitory urge, while rituals do not. Other comorbid conditions include other anxiety disorders and oppositional defiant disorder (Ale & Krackow, 2011).

The assessment of OCD is complex. Grados and Riddle (1999) indicate that children with OCD may present to a variety of professionals not adequately trained to recognize the disorder, including pediatricians and dentists (e.g., bleeding gums from excessive toothbrushing). Moreover, high comorbidity with other disorders poses significant challenges given the numerous “OCD-like” symptoms that may be present. Therefore, it is important for clinicians to determine the purpose of presenting behaviors as opposed to simply assessing their form (Berman & Abramowitz, 2010). The progression of OCD may be intensified if symptoms are not recognized and treated promptly.

Clinicians should use a multi-method, multi-informant approach to assessment involving the use of structured and unstructured diagnostic interviews, self-report measures, clinician-administered inventories, and parent and teacher report measures. This approach offers qualitative and quantitative information regarding the onset, frequency, intensity, and duration of associated rituals. Sloman and colleagues (2007) argue that it is important to obtain a social developmental history from the child’s parents to provide information regarding the child’s psychological development and medical history. Behavioral observations across multiple time periods and settings to gain an understanding of the factors that maintain symptoms within the child’s environment are indicated.

Standardized measures: Given that most children struggling with anxiety and obsessive compulsive spectrum disorders tend to underreport symptoms, it is critical to interview both parent(s) and child. Common diagnostic interviews include the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV-C/P; Silverman & Albano, 1996) for children and adolescents and the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) for younger children (Kaufman et al., 1997). The ADIS-IV-C/P was developed for children and adolescents aged 6–18 years and features questions to establish the history of the problem along with separate clinician rating scales that assess for degree of associated impairment (Silverman & Ollendick, 2008). These interviews offer the opportunity to differentiate OCD from other psychiatric disorders. The administration of diagnostic interviews may require extensive training and be time consuming, limiting their use (Merlo, Storch, Murphy, Goodman, & Geffken, 2005).

Thus, it is important to use self-report and other report measures to obtain additional information on symptoms, their severity, and functional impairment. The current gold standard is the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). The CY-BOCS is a 10-item semi-structured questionnaire that measures OCD severity in children over the past week and includes a symptom checklist featuring a summary of commonly endorsed related symptoms (Freeman, Flessner, & Garcia, 2011). A downward extension of the Leyton Obsessional Inventory (LOI) features a 20-item child version designed for children aged 8–17 years that explores obsessive thoughts and accompanying rituals (Grados & Riddle, 1999), taking about 5 min to complete.

In addition to measures of OCD symptomatology, Calvoressi and colleagues (1999) developed the Family Accommodation Scale. This 9-item measure assesses the level of familial accommodation of a child’s obsessive-compulsive behavior during the past month, including helping the child avoid objects/places and modifying family routines (Merlo et al., 2005). This scale has good psychometric properties and can be completed by parents or other family members in approximately 5 min. Items include “How often did you provide items for the patient’s compulsions” and “Has the patient become distressed/anxious when you have not provided assistance? To what degree?”

Cognitive-behavioral therapy (CBT), specifically exposure and response prevention (ERP), and pharmacological treatment with SSRIs, or a combination of CBT and medication, are considered current evidence-based treatments for OCD in children and teens (Freeman et al., 2014; Pediatric OCD Treatment Study (POTS) Team, 2004). Recent studies also suggest the efficacy of family-based CBT and acceptance and commitment therapy (ACT). Since OCD is a chronic condition, people suffering from it often go back periodically for booster sessions (March & Mulle, 1998).

Although manualized treatments are available, treatment should be individualized for each child based on several factors, including symptom severity and comorbidity with other disorders. Given the amount of time children spend at school, educators and other school staff play an important role on the initial identification of OCD in children and assist in the development of a sound individualized treatment plan that helps the child achieve educational goals without making accommodations that may worsen symptoms.

March and Mulle (1998) developed a CBT treatment manual for children with OCD aged 7–17, composed of four steps: psychoeducation, cognitive training, mapping OCD, and graded exposure and response prevention . During the psychoeducation stage, OCD is described as a medical condition related to brain function. To help families understand the importance of treatment, OCD is presented as analogous to diabetes or asthma (CBT for OCD as exercise for diabetes). For younger children, OCD is described as “a worry monster” or “hiccups of the brain.” By differentiating the child from the OCD, the child and family learn to externalize OCD and begin seeing it as something they can have control over by “bossing back” OCD.

Cognitive training involves teaching youngsters cognitive tools utilize to “boss back” OCD. ERP is identified as the main strategy for the child’s battle against OCD, and the therapist, family members, and often educators are identified as allies of the child (March & Mulle, 1998). Child-friendly concrete examples are used to explain the rationale for ERP, for example, “bossing back the worry monster” who tries to tell you to do things it wants you to do (Freeman et al., 2008).

Mapping OCD focuses on assessing the child’s symptom intensity, topography, triggers, and consequences. This assists the therapeutic team—the child, parents, and therapist—to learn situations in which the child is and is not successful in resisting compulsions. This “map” helps strengthen the externalization of OCD from the child and the belief that child and team are on the same side.

Graded Exposure and Response Prevention (ERP) is the core of CBT for OCD and is used with children as well as adults. Graded exposure consists of exposure to situations that produce unwanted feelings (anxiety, fear) in the child, such as touching a toilet seat when the child has contamination fears. Understandably, children may hesitate to engage in graded exposure. Clinicians should remind the child that each time a feared situation is practiced, the easier it will become. Response prevention consists of blocking or minimizing ritualistic and/or avoidance behavior, such as washing the hands after touching the toilet seat. The therapist and child review progress during every session in order to ensure the implementation of ERP exercises is appropriate and help the child learn to make these evaluations on his or her own. In the school setting, teachers should work with the child to help them respond obsessive thoughts in positive ways as opposed to providing excessive reassurance.