OCD can appear in children as young as three, often showing up as repetitive behaviors and requests for reassurance. Fortunately, pediatric OCD is highly treatable with exposure and response prevention (ERP) therapy, and parental support.
OCD is a chronic mental health condition that we typically associate with adults. However, it affects around 1 to 3% of children and adolescents. According to the Anxiety & Depression Association of America (ADAA), OCD is prevalent among 2.2 million people in the United States, and while the average age of onset is 19, 25% of cases occur by age 14. OCD can appear in children as early as 3 years old—although it is rarely diagnosed before age 5.
As a parent or caregiver, there’s nothing more important than your child’s safety and well-being. But when a child develops obsessive-compulsive disorder (OCD), the source of their distress may not always be clear. One of the most difficult parts about recognizing pediatric OCD is that it can look very different in each child who develops it. One child may have strict rules and restrictions around what he eats. Another kid might tap things incessantly, while another may repeatedly ask her parents for reassurance that they are safe.
While identifying the signs of OCD can be tricky, knowing what to look for is the first step to helping your child. More importantly, it’s crucial to know that OCD is highly treatable, even in very young children. As you learn more about OCD, you can also learn how to help your child better manage their symptoms so they can get back to enjoying life.
Read on to learn more about how to identify symptoms of OCD in toddlers and children, why OCD develops in kids, how it’s treated, and how you can best support your child along the way.
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What are the signs and symptoms of OCD in children?
OCD is characterized by a cycle of obsessions and compulsions. Obsessions are intrusive thoughts, feelings, urges, images, and sensations that cause distress and anxiety, while compulsions are the physical or mental behaviors done to alleviate distress, or to prevent a feared thing from happening.
Just like adults with OCD, the symptoms children experience can vary. One survey of children ages 4-8 found that having multiple obsessions and compulsions was common. The study also showed that preoccupations with contamination, harm and symmetry were the most prevalent obsessions, and washing, checking, and ordering rituals were the most frequently appearing compulsions.
A big clue that your child might be showing signs of OCD is if they become secretive about their behaviors, indicating that their compulsions have become very important and necessary to them. Another tell-tale indicator of the condition is how much time it takes up—if your child appears to be spending an hour or more a day on their compulsive behaviors, they may have OCD.
While obsessions and compulsions can fluctuate over time and developmental stages, there are some common symptoms that may suggest a child has OCD.
Signs of OCD in toddlers and pre-schoolers (3 to 5-year-olds)
Young children can have a different experience of OCD than older children or teens, as their sense of awareness, reality, and rationalization skills are not yet as keenly developed. “Kids at this age lack the mental capacity to really put into words what their internal private experience is,” says NOCD Therapist Dr. Nicholas Farrell, PhD, LP.
Some of the most common obsessions in 3 to 5-year-olds include:
- Fear of contamination: Your child may be fearful of germs, dirt, or other contaminants.
- Fear of harm to loved ones: Your child may be repeatedly disturbed by thoughts of all the bad things that could happen. This can lead them to practice compulsive behaviors, but it also sometimes leads kids to avoid specific people, places, or things they believe are dangerous.
- Need for symmetry or order: Your child may develop a need for order and symmetry. They may insist on lining up their toys in a particular way, arranging items based on size, color, or shape, or performing specific actions in a particular order, such as touching each item in a specific sequence.
- Superstitions (magical thinking OCD): Your child might worry that their thoughts or actions will cause harm to a loved one. They may practice rituals, like touching everything in a room or lining things up in a certain order, because their OCD tells them it will prevent bad things from happening.
Common compulsions among toddlers and preschoolers include:
- Repetitive behaviors: Young children may engage in repetitive behaviors like tapping, touching, or repeating certain words or actions.
- Counting: Some young children may begin to count things or actions in a specific sequence.
- Seeking reassurance: Your child may frequently ask questions or seek reassurance to alleviate anxiety about whether they’ve made a mistake or if something bad will happen.
- Hoarding items: Your child may have difficulty throwing things away, even if the items are old or seemingly useless.
- Rubbing: Your child may feel the need to rub or touch specific objects or areas on their body as a form of reassurance.
- Repetitive hygiene rituals: Your child may engage in frequent handwashing or cleaning to avoid contamination. Your child may become distressed if they feel dirty or if they can’t complete the action in a specific way.
- Avoidance: Your child may engage in avoidant behaviors, such as refusing to eat specific foods, participate in certain activities, or play with toys they associate with fear or contamination.
Toddlers and preschoolers may feel temporarily better after completing a compulsion, but not be able to analyze the obsessive thoughts underpinning this pattern of behavior.
Signs of OCD in 6 to 12-year-olds
Children who are in elementary and middle school have similar obsessions to younger children with OCD, including fear of contamination, intrusive thoughts about harm, the need for symmetry, and magical thinking. They may also have similar compulsions like checking, counting, seeking reassurance, hoarding, and avoiding.
“Children in this age group struggle to be flexible, have highly specific rules about how things need to be done, and can become extremely upset if those rules are not followed,” says Tracie Ibrahim, MA, LMFT, CST, Chief Compliance Officer at NOCD.
In addition to the symptoms mentioned above, signs of OCD in 6 to 12-year-olds may also include:
- Confessing “bad thoughts”: Your child may feel the need to confess intrusive or disturbing thoughts to others, believing that admitting them will prevent something bad from occurring.
- Increased perfectionism: Sometimes a child will feel the need to do something to perfection or until it feels “just right,” even if they don’t know why or what that means. This may include entering and exiting a room repeatedly or rereading or rewriting something until it feels right. Or, they may count certain objects, words, numbers, or multiples of numbers. Your child may excessively fret about the neatness of their schoolwork, feel they have to arrange things in a pattern, or tidy their room in a specific way.
- More complex intrusive thoughts: Six to 12-year-old children may experience more specific or abstract intrusive thoughts. These might include worries about making a mistake that could lead to dire consequences or fears of acting inappropriately in social situations.
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Signs of OCD in teens
As children reach their teenage years (13 to 19-year-olds) and experience hormonal changes related to puberty, they tend to face OCD symptoms related to sex, sexuality, or physical changes in their bodies. Teens might also experience scrupulosity OCD, a subtype of OCD that revolves around religion, ethics, and morals—although the types of OCD symptoms will vary depending on the individual.
How pediatric OCD differs from adult OCD
Obsessions and compulsions between children and adults may look similar, such as compulsions like checking, seeking reassurance, or repeating certain behaviors. However, there are certain aspects of obsessions and compulsions that are unique to children:
- Fear of parental death: Your child may have specific obsessions related to the fear of losing their parents, fearing that something bad might happen to them. This can manifest as a child repeatedly asking if their parents are safe or performing rituals to prevent harm from coming to them.
- Involvement of family members: Your child may involve family members in their rituals, often seeking reassurance or requiring them to participate in certain behaviors to alleviate their anxiety.
- Minimal sexual themes: Unlike adults and teens, children with OCD rarely experience sexual themes in their obsessions.
- Tic disorders: In some cases, children with OCD may also develop a tic disorder, where they exhibit sudden, repetitive movements or sounds.
What causes OCD in children?
If your child develops OCD, the most important thing to remember is that it isn’t your fault, and it isn’t your child’s fault. It is imperative that you, as a caregiver, let go of feelings of guilt and shame, and don’t blame yourself for doing something wrong.
While the exact cause of OCD in children isn’t clear, research suggests three key factors that play a role in its development:
1. A family history of OCD
Studies suggest that OCD has a strong genetic component. Kids with a first-degree relative (such as a parent or sibling) who has OCD are three to 12 times more likely to develop the condition.
In addition to genetic predisposition, OCD can develop through learned behavior when kids observe safety behaviors and rituals performed by their family members.
2. Trauma or stress
There may be a link between stressful or traumatic events and early-onset OCD. But it’s important to note that post-traumatic stress disorder (PTSD) can sometimes get mistaken for OCD. Both of these conditions can involve unwanted, intrusive thoughts, and are driven by a need to neutralize those thoughts. However, PTSD is typically focused on avoiding triggers that bring up distress from a past experience, whereas OCD is focused on developing rituals that temporarily relieve distress about future outcomes.
3. Infections
Studies have also shown that OCD can sometimes be triggered by a condition linked to strep throat infections called PANDAS/PANS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep). This usually affects children between the ages of 3 and 12 and can lead to anxiety, tics, obsessive thoughts, compulsive behaviors, and even changes in mood or personality.
What sets PANDAS apart from typical OCD is that its symptoms tend to appear suddenly and intensify quickly (approximately 4-6 weeks after having a strep infection) while typical OCD symptoms usually develop more gradually over time. To learn more, visit the PANDAS Network.
How is pediatric OCD treated?
If you believe your child might be experiencing OCD symptoms, Dr. Farrell says that it’s best to be on the side of caution and have your young one evaluated. While OCD can’t technically be cured, with the right treatment, you may find that your child’s symptoms are drastically reduced or go away altogether.
When finding a therapist for your child, be sure to seek out someone who is trained in exposure and response prevention (ERP) therapy. This specialized form of cognitive behavioral therapy (CBT) is highly effective for treating OCD in children and teens.
During ERP therapy, your child will learn how to face their fears and resist the urge to engage in their compulsions (a process known as response prevention). The ERP therapist will teach your child how to cope with their obsessive thoughts, helping them gain a sense of freedom from their compulsions. ERP exercises can be adapted to your kid’s needs and situation—they’ll practice ERP exercises in sessions with their therapist, as well as at home in between appointments.
Having family support is important for any child doing ERP therapy. However, ERP treatment for toddlers will need to include significant involvement from parents, other caregivers, and siblings. Because it’s crucial not to enable a young child’s compulsions at home, successful ERP therapy for toddlers may require near-constant active participation from family members.
ERP might sound hard, and it can be at first, but the great benefit of working with a trained ERP therapist—especially one who has experience working with children—is that your child won’t be alone during this process. They’ll have the support and tools they need to cope with the anxiety. And when kids stop engaging in compulsions, they learn that the things that once felt terrifying are actually often quite manageable.
How parents can help kids with OCD
Get involved
Your involvement in treatment can make a significant difference in your child’s progress. You can support your child in a number of ways, like being there when they do ERP exercises at home, staying in touch with your child’s therapist, and helping your child navigate any challenges and setbacks that arise over the course of their treatment. And by educating yourself about OCD, you can better understand what your child is going through. Your involvement not only reinforces your child’s treatment but also shows them they are not alone in managing their challenges.
Consider joining a support group for parents—other families are also dealing with the same struggles and it can be extremely helpful to connect with them.
Avoid providing reassurance
Although you mean well and want to reassure your child when they ask questions like, “Is everything okay?” or “Will something bad happen?,” providing constant reassurance can actually make the anxiety and compulsions stronger.
Some common examples of parental reassurance include:
- Providing verbal reassurance (e.g., saying “No you will not harm your sister” for a child with harm OCD)
- Buying excessive amounts of hand sanitizer or assisting your child with compulsive hand washing
- Excessively washing your child’s clothes
- Assisting your child as they reorganize items in an attempt to be symmetrical or perfectly aligned
- Allowing or assisting your child with avoidance behaviors
It’s tough not to provide reassurance, but stopping this habit will ultimately help your child to break the cycle of anxiety and compulsive behaviors. Working together with your child’s ERP therapist will also help you and your family stay supportive without accommodating your child’s OCD.
A note for parents with OCD
Being a parent with OCD and having a child with OCD brings its own unique set of challenges. However, you can still give your child the support they need to get their symptoms under control. In fact, your own experience with OCD can give you valuable insights into what your child is going through, and your personal understanding of obsessions and compulsions can help you relate to your child’s experiences in a way that others may not.
Caring for a child with OCD might also trigger your own OCD, so make sure that you’re setting aside time to do what you need to avoid burnout and support your mental health.
Bottom line
Parenting is tough, period. Trying to identify and/or manage pediatric OCD in addition to your day-to-day responsibilities as a caregiver can quickly become overwhelming. However, there is hope, and you’re not alone.
If you think your child is showing signs of obsessive-compulsive disorder, don’t hesitate to reach out to an OCD specialist—OCD is highly treatable, even in young children. ERP therapy can be challenging, but by sticking with it, your child could see a significant reduction in their symptoms within eight to sixteen weeks. By getting involved in your child’s treatment, educating yourself about OCD, and staying supportive without providing reassurance, you’ll be setting your child up for success.
Key Takeaways
- Pediatric obsessive-compulsive disorder (OCD) can show up in different ways depending on a child’s developmental stage.
- Exposure and response prevention (ERP) therapy, a specialized form of cognitive behavioral therapy (CBT), is the most effective treatment for children and teens with OCD.
- Parents, family, and caregivers play a crucial role in treating pediatric OCD.