How to Recognize Signs of OCD in Children

Although we often think of obsessive-compulsive disorder (OCD) as an illness that affects mostly adults, between 0.25% and 4% of children will develop OCD. The average age of onset is approximately 10 years old, although children as young as 5 or 6 may be diagnosed. In rare cases, children can start showing symptoms around age 3. While there are many similarities between adult-onset and childhood-onset OCD, there are also many important differences, too. Let's take a look.

Characteristics of OCD in Children

Obsessive-compulsive disorder (OCD) is a mental health condition characterized by obsessions and compulsions that interfere with daily life.

OCD was formerly classified as an anxiety disorder because the obsessive thoughts characteristic of the disorder can lead to severe anxiety and the compulsions or rituals performed are often an attempt to reduce the anxiety caused by obsessions.

In the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), OCD was moved to its own disorder class of "Obsessive-Compulsive and Related Disorders."

OCD is said to be childhood-onset if obsessions and compulsions occur before puberty. Interestingly, while boys are more commonly affected by childhood-onset OCD, this trend reverses following puberty. As well, boys with childhood-onset OCD appear to have a greater risk for related conditions including tic disorders.

Children with OCD often have less insight into their obsessions than adults and may not yet have the capacity to understand the irrational nature of their thoughts. This, combined with a limited and/or developing verbal ability, can make it difficult to make a proper diagnosis.

The content of a child’s obsessions as well as the compulsions can be different from that of adults.

• Children with OCD often have specific obsessions related to the death of their parents.
• Children’s obsessions rarely emphasize sexual themes, although it is important to note that adolescents may actually experience a greater incidence of sexually focused obsessions.
• The rituals or compulsions of children may be more likely to involve or be centered around family members.
• Children with OCD may hoard more frequently than adults with the disorder.
• Childhood-onset OCD also seems to signal a higher risk of tic disorders and attention-deficit/hyperactivity disorder (ADHD).

Identifying OCD in Children

The signs and symptoms of OCD in children can be categorized by obsessions and compulsions.

Common obsessions among children with OCD include:

• Disturbing and unwanted thoughts or images of violent or disturbing things, like harming others
• Extreme worry about bad things happening or doing something wrong or lying
• Feeling that things have to be “just right”
• Preoccupation with order, symmetry, or exactness
• Worries about getting sick, or getting others sick, or throwing up

Compulsions are often (but not always) related to obsessions. For example, if the child fears germs, they may be compelled to wash their hands repeatedly.  

Common compulsions among children with OCD include:

• Counting things over and over again
• Elaborate rituals that must be performed exactly the same way each time (i.e. a bedtime ritual)
• Excessive hand washing, showering, or brushing teeth
• Excessively repeating sounds, words, or numbers to oneself
• Ordering or rearranging things in a particular or symmetrical way
• Repeated checking (such as re-checking the door is locked, oven is off, or homework is done right)
• Repeatedly seeking reassurance from friends and family

OCD can co-exist with (and also be mistaken for) several other disorders that include rigid routines and/or repetitive behaviors or rituals:

• Anxiety disorders
• Attention-deficit/hyperactivity disorder
• Autism spectrum disorders
• Tic disorders/Tourette syndrome

Causes

While the exact cause of OCD in children is unknown, researchers believe several factors play a role:

• Brain structure: Imaging studies have found a connection between OCD and abnormalities in the frontal cortex and subcortical structures of the brain.
• Early-life trauma: Some studies have found a link between early-life trauma, like sexual assault, and symptoms of OCD in prepubescent girls.
• Genetics: While there is not a specific “OCD gene,” there is evidence that particular versions (alleles) of certain genes may signal greater vulnerability. What’s more, OCD has been found to run in families: The closer the family member and the younger they were when symptoms started, the higher your risk.
• Stress: Stress from relationship difficulties, problems at school, and illness can be strong triggers for symptoms of OCD in children.

Sudden-Onset OCD

In about 5% of children, OCD is caused by an autoimmune reaction within the brain known as PANDAS or autoimmune subtype. PANDAS form of OCD is thought to be triggered by an infection with the same bacteria that cause strep throat and scarlet fever. As the child’s immune system fights the infection, it becomes confused and starts to attack an area of the brain called the basal ganglia.

The PANDAS form of OCD has a few key characteristics, such as the rapid onset of symptoms, that help doctors distinguish it from more typical forms of childhood OCD. Research has shown that only those children who are genetically predisposed to OCD or tics are vulnerable to developing this form of OCD. The PANDAS form of OCD may entail some differences in treatment, too.

Treatment

In most cases, the current recommended treatment for childhood-onset OCD is a combination of individual or group cognitive behavioral therapy (CBT) and medications that increase levels of the brain chemical serotonin such as selective serotonin reuptake inhibitors (SSRIs).

Cognitive Behavioral Therapy

One of the most popular and effective forms of behavioral therapy for OCD is child-modified exposure and response prevention therapy (ERP). ERP involves exposing children to the anxiety that is provoked by their obsessions and then preventing the use of rituals to reduce their anxiety. This cycle of exposure and response prevention is repeated until children are no longer troubled by their obsessions and/or compulsions.

It is not unusual for both adults and children with OCD to ask others to participate in their compulsions, and family members often oblige so as to reduce their loved one’s anxiety, especially when it is a child. For treatment to work, compulsions need to stop and family members must be aware of this.

Parents can also be an invaluable resource in helping the therapist to develop ways of presenting material that will resonate with and make sense to the child. On a day-to-day basis, parents can help remind young children that their OCD is the “bad guy” that is responsible for their symptoms, and they and their parents and family are the “good guys.” Such a technique can help reduce the chances a child will feel blame or shame for having OCD.

Medications

If severe enough, treatment may include a combination of CBT and medications. SSRIs are often used to help reduce a child's anxiety, however, these drugs must be used cautiously in children and adolescents as they may increase the risk of suicide in this age group.

Three SSRIs have FDA approval for use in children and adolescents with OCD:

• Luvox (fluvoxamine): Approved for children age 8 and older
• Prozac (fluoxetine): Approved for children age 8 and older
• Zoloft (sertraline): Approved for children age 6 and older

If OCD is caused by PANDAS, treatment may include the following:

• Antibiotics (penicillin, azithromycin)
• Intravenous immunoglobulin
• NSAIDs and corticosteroids
• Plasma exchange
• Tonsillectomy

Coping

While there is no doubt that parenting children with OCD can be a challenge, there are ways to cope. Getting informed about OCD, particularly as it is experienced by children, is the essential first step that every parent of a child with OCD should take to become an effective advocate for their child and family. Learning more about your child’s OCD will also help to reduce your own stress levels and make it easier to carry through with at-home exposure exercises.

Here are a few more tips to consider:

• Work on fostering a strong partnership with the various professionals involved in your child’s care.
• Don’t be afraid to ask questions and ask about resources that you can take home to better absorb new information in small bits.
• Engage your partner and/or family. If you are having trouble engaging your partner in becoming educated about your child’s OCD or helping out with at-home exposure exercises, talk about it—don't sweep it under the rug. Often, a partner’s reluctance to help out simply reflects their own anxiety about the situation and does not mean they don’t want to help the child.
• Seek support. Look into available resources within your community. A good starting point can be a support group where people share tips for coping with a child who has OCD.

A Word From Verywell

Finally, it is important to never give up hope. While there is no "cure" for OCD, many different treatments are available, so if the first strategy doesn’t work, keep trying. Sometimes it is simply a matter of finding the right therapist or the right combination of medication and psychotherapy. With the right treatment, many children are able to find relief from their symptoms and learn coping strategies to thrive in daily life. If you think your child may have OCD, don't wait to talk to your physician.