Signs of OCD in Children
Children with OCD present with repetitive, intrusive, unwanted thoughts (obsessions) and/or repetitive behaviors or mental acts they feel driven to perform (compulsions), which are time-consuming (>1 hour daily) or cause significant distress and functional impairment. 1
Core Clinical Features to Identify
Obsessions (Intrusive Thoughts)
Children experience repetitive and persistent thoughts, images, impulses, or urges that are intrusive, unwanted, and commonly associated with anxiety 1:
- Fear of contamination - concerns about dirt, germs, or getting sick 1
- Harm-related concerns - persistent worries about harm coming to themselves or loved ones 1, 2
- Forbidden or taboo thoughts - intrusive aggressive, sexual, or religious thoughts 1
- Symmetry concerns - need for things to be "just right" or perfectly ordered 1
Important caveat: Young children may have difficulty identifying or describing their obsessions, making recognition more challenging than in adults 1
Compulsions (Repetitive Behaviors)
Children feel driven to perform these behaviors in response to obsessions or according to rigid rules 1:
- Washing/cleaning rituals - excessive handwashing, showering, or cleaning objects 1
- Checking behaviors - repeatedly checking locks, homework, or that nothing bad happened 1
- Mental rituals - silent counting, praying, or repeating phrases to neutralize fears 1, 2
- Ordering/arranging - lining up objects, straightening items repeatedly 1
- Counting or repeating - performing actions a specific number of times 1
Functional Impact Indicators
Look for these signs of impairment 1:
- Time consumption - rituals taking more than 1 hour per day 1
- Academic interference - difficulty completing schoolwork, attending class 3, 4
- Social isolation - avoiding peers due to embarrassment or time spent on rituals 5, 4
- Family disruption - demanding family participation in rituals or causing household tension 4
- Avoidance behaviors - curtailing activities to prevent triggering obsessions 1
Age-Specific Presentation Patterns
Early onset is common: Nearly 25% of males with OCD have symptom onset before age 10 1. The disorder can significantly impact development, with approximately 50% of children continuing to have OCD into early adulthood 5.
Children may hide behaviors due to embarrassment or fear of peer victimization, making detection more difficult 4. Parents may also attempt to conceal their child's symptoms 4.
Key Differentiating Features from Normal Development
While ritualistic behavior is normal in child development, OCD rituals are distinguished by 5, 4:
- Distress and resistance - the child recognizes behaviors are excessive and wishes for more control 1
- Ego-dystonic nature - thoughts feel intrusive and unwanted, not like genuine concerns 2
- Rigid, repetitive patterns - compulsions follow strict rules rather than flexible preferences 2
- Anxiety-reducing function - behaviors are performed to prevent dreaded outcomes, not for gratification 6
Common Comorbidities to Assess
OCD in children frequently co-occurs with 5, 7:
- Depression and anxiety disorders 5, 7
- Tic disorders or Tourette syndrome 5, 7
- Attention-deficit/hyperactivity disorder 7
- Learning difficulties 7
Critical Pitfall to Avoid
Do not confuse OCD compulsions with impulsive behaviors (such as impulsive buying or gratification-seeking actions), which are ego-syntonic and fundamentally different from the anxiety-reducing, ego-dystonic nature of OCD compulsions 6. OCD is explicitly distinguished from impulse-control disorders in diagnostic criteria 1, 6.