Anxious Child Spits Compulsively - Normal or OCD?

I'm glad you wrote. I obviously cannot diagnose any condition without assessing your child, but it is possible that what you are describing may be symptoms of Obsessive Compulsive Disorder, which requires professional intervention. The good news is that most kids who receive cognitive behavioral therapy for OCD in childhood outgrow their symptoms, or at least learn to manage them, by the teen years.

Here's how OCD works. We all get anxious many times a day. Anything that provokes a disgust reaction -- anything we consider "gross"-- makes us anxious. Generally, we learn to tolerate our anxiety, and we do something to make ourselves feel better. For instance, if it is someone's messy drawer, we might reassure ourselves that there is nothing actually gross in it, or at least that it is not our drawer. If it is actually gross -- an unflushed toilet -- we might take the action of flushing the toilet and then washing our hands. This decreases our anxiety about the situation, and we move on with our lives.

However, some kids find the anxiety intolerable and they develop a physical reaction to manage their anxiety. Compulsive hand-washing and spitting are the most common. Unfortunately, these behaviors don't get at the root of the problem, which is the anxiety, and since anxiety tends to feed on itself and makes the person more anxious, the number of things that disgust the child and/or make her anxious tend to increase over time, setting up a vicious cycle.

That your daughter is expressing great anxiety in response to her disgust reactions, and that she is spitting both then and when she gets nervous for other reasons (such as her violin performance anxiety) suggest that she should be evaluated by a psychologist who specializes in OCD. (I want to emphasize again that I obviously cannot diagnose any condition from a letter, but am theorizing the most likely reason for your daughter's behavior.)

Cognitive behavioral therapy (CBT) is at this point considered the most effective treatment for OCD behaviors such as compulsive spitting. The child is slowly exposed to objects that cause anxiety and is helped to tolerate the anxiety without resorting to the compulsive behavior.

Tolerating the anxiety slowly empties the emotional backpack of whatever is making the child so anxious. This is true for all of us--when we are able to just sit with whatever is making us anxious, and breathe through it, the anxiety diminishes. So this is not simply a "conditioned" response. This is actually working through the anxiety.

Learning to manage their anxiety gives the child an essential tool they can use in daily life, which reduces the number of times they feel anxious and/or disgusted, as well as the need to spit.

There are also medications that are sometimes prescribed for kids with severe OCD symptoms who don't respond to cognitive behavioral therapy by itself, but from your description your daughter's symptoms are mild and most likely would not require medication. But a specialist will be able to do a complete assessment for OCD, including evaluating the possibility of PANDAs, which is an infection-induced tendency to OCD symptoms that is characterized by acute onset of the OCD symptoms (as opposed to gradual development of the symptoms.)

As for your daughter's other tic -- holding the marker -- I wouldn't worry about it by itself. It is just an indication that she finds it challenging at times to manage her anxiety.

I want to add that your handling of this has been totally appropriate, i.e. showing your daughter your dresser drawer and asking why she is spitting. It may have temporarily increased your daughter's anxiety, but was necessary for you to help her. At this point, in addition to finding an experienced therapist, there are some specific ways you can support your daughter:

1. Help your daughter become more aware of her anxiety so instead of simply being in the grip of it and reacting, she can learn to manage it. So you might develop a phrase you use to suggest that she check in with her body, and take a deep breath, and simply notice what is going on inside her. That is likely to feel uncomfortable to her in the beginning, but will ease the anxiety the more she does it, and so will begin to be a helpful "go-to" that she can use when she starts to get hijacked by anxiety.

2. Teach your daughter specific skills and habits that will decrease her anxiety. for instance, get your hands on a relaxation audio for kids and do it with her. she will learn how it feels to shift out of anxiety and into a feeling of more calm and ease, so that she can reproduce that at will. There are unlimited audios and unlimited practices, from guided meditations to breathing to yoga. See what she likes and help her use it regularly so that it becomes a habit.

3. Support your daughter to develop emotional intelligence. When humans have emotions they don't feel comfortable expressing, they push them down inside. But those emotions are always trying to surface to be felt, which heals and releases them. We experience that inner turbulence as anxiety. So helping your daughter put her emotions into words or express them through art will help reduce her anxiety.

4. Get your daughter laughing every day. It may sound crazy, but laughter reduces anxiety. Psychologically, that's because it siphons off the top layer of fear (which is mild anxiety) in the emotional backpack. Physiologically, it's because laughter transforms the body chemistry, reducing stress hormones and increasing feel-good hormones.

5. Do some work on your own worries about your daughter, so you don't inadvertently make her more anxious with your concern. That might be as simple as writing in a journal, or you may want to schedule a few sessions with a parenting coach or counselor.

6. Read some books on supporting kids with anxiety, so that you can learn more strategies to support her. My two favorites are The Opposite of Worry by Dr. Lawrence Cohen and Freeing Your Child from Anxiey by Tamar Chansky.  Chansky also has a book specifically on helping kids with OCD: Freeing Your Child from Obsessive-Compulsive Disorder.

The good news is that your early attention to this issue is terrific and will hopefully help your daughter to put it behind her quickly. The even better news is that you will be teaching your daughter skills to manage anxiety that will serve her throughout her life.