The most common OCD symptoms in children

Maybe your child always organizes their crayons in the same deliberate way and gets upset if they’re out of order. Or maybe they insist on tying and untying their shoelaces a certain number of times before leaving the house. These kinds of behaviors can hint at obsessive-compulsive disorder (OCD), a condition that’s more than simply liking things done a certain way.

OCD is one of the most common mental health disorders today, affecting 2 to 3% of Americans at some point in their lives. While the average age of onset for OCD is 19, it can occur any time—even as early as preschool. In fact, research shows that around 1 to 3% of children and adolescents will develop the disorder at some point. This is known as “early-onset OCD,” and it’s slightly more common in boys. The average age for early-onset OCD is 10 years old.

The good news? Studies have shown that children respond just as well to OCD treatment as adults do. Still, according to Amalia Sirica, LCSW, a licensed therapist with NOCD who specializes in OCD, the earlier you can catch the condition, the better. That’s because, she says, children’s minds have more plasticity—meaning they’re more malleable and flexible, so it could be easier to change their thought patterns and behavior while their brains are still developing than it would be later in life. 

Seeking professional support can make a world of difference in helping your child live a happy, healthy, and fulfilling life. And it can alleviate the emotional burden on your family that comes with trying to manage your child’s OCD symptoms on your own. 

If you suspect your child may be struggling with obsessions and compulsions, here’s what you need to know about the common symptoms and treatment options for early-onset OCD.

OCD explained

People with OCD experience obsessions, which are unwanted thoughts, feelings, images, sensations and/or urges that keep arising and causing distress, as well as compulsions, which are repetitive acts that are performed to temporarily relieve the anxiety that obsessions create. While OCD is technically considered an anxiety disorder, the compulsions are what distinguish OCD from anxiety. With anxiety, obsessive thoughts don’t typically trigger specific behaviors and actions.

OCD can be tricky to diagnose in kids, and there are several reasons for this. Comorbidity is a term used when someone has two or more conditions at the same time—and in children, OCD can sometimes be comorbid with attention-deficit/hyperactivity disorder (ADHD), other anxiety disorders, and mood disorders. In fact, studies show that up to 88% of young children with OCD also meet the diagnostic criteria for at least one other mental health condition. This can make it more challenging to suss out the OCD symptoms.

It’s also worth noting that children—especially at a younger age—may not even realize that their thoughts or behaviors are out of the ordinary. As Sirica points out, children aren’t always able to articulate what they’re thinking or feeling, which is crucial for identifying OCD and getting a diagnosis. She also says that since OCD can present differently in children than in adults, parents may be more likely to miss the signs—or assume their kids are merely acting out. 

And, according to Sirica, parents often begin accommodating their children’s compulsions—with very good intentions of soothing their distress. For example, they might open doors for their kid, who is worried about germs, or answer repeated questions from a child with a checking compulsion. These kinds of accommodations may prevent the child from becoming agitated or upset, but they also fuel the cycle of OCD through negative reinforcement. And by masking the symptoms, Sirica says these accommodations may cause the kid’s OCD to go untreated for longer.

Some children may be secretive about their compulsions due to the shame that can be attached to them, which can also make it hard to recognize the symptoms of OCD. Plus, with early-onset OCD, the symptoms tend to appear more gradually, which can make it more difficult to detect.

What are the signs and symptoms of OCD in children?

Being able to recognize the signs of OCD can empower you to get help for your child more quickly. 

OCD starts with your child’s thoughts. Here are some common obsessions to look out for:

• A preoccupation with germs, or fear of touching contaminated surfaces
• Intrusive, troubling impulses, images, or thoughts—for example, about getting injured or hurting others
• Superstitious beliefs about needing to perform certain acts in order to prevent bad things from happening
• Being overly concerned about unintentionally hurting others, or feeling overly responsible for others’ safety and well-being
• A strong fear of misplacing things
• Unwanted thoughts that relate to sex or religion
• An obsession with bathing or cleanliness
• Sudden, persistent worries about getting sick or dying, or a loved one falling ill or dying
• Persistent doubts about household safety—for example, frequently worrying about whether or not the windows are closed at night
• An intense need to remember seemingly minor things

Compulsions may offer your child temporary relief from their obsessions, but they can be extremely time-consuming and only feed the vicious cycle of OCD. Here are some common compulsions that children may develop:

• Spending long periods of time counting and recounting things
• Verbally repeating specific words over and over either out loud or silently
• Symmetrically arranging objects, such as food on their plate
• Excessive hand washing—dozens or more times a day
• Checking and rechecking something over and over, such as constantly going back over their homework to make sure it was completed in a certain way
• Being rigid about the order in which certain things are done, like how they put on clothing
• Hoarding unnecessary objects, like old worksheets from school or broken toys
• Touching or moving body parts in a certain way to achieve symmetry
• Adhering to specific routines and rituals in the morning or at bedtime—and having to start the entire routine over if it’s disrupted

Research has shown that some of the most common obsessions in children are preoccupations with contamination, harm to themselves or others, and symmetry—whereas the most common compulsions involve washing, checking, and ordering rituals. One study found that 96% of children experience multiple compulsions, with an average of around four. 

Something to keep in mind: Just because your child likes to keep their desk orderly, occasionally double checks to make sure the door is locked, or avoids touching germ-contaminated surfaces doesn’t necessarily mean they have OCD. However, if they worry that something catastrophic will happen to them or a loved one if they don’t engage in their compulsions—or if their obsessions and compulsions become excessively time-consuming and cause significant problems in their everyday lives—that can suggest OCD. 

What causes OCD in children?

Sirica says that the exact cause of OCD in children isn’t clear. If your child develops the condition, the most important thing to remember is that it isn’t your fault, and it isn’t your child’s fault.

Research has found that a family history of OCD is one of the top risk factors—particularly with early-onset OCD. Kids with a first-degree relative (such as a parent or sibling) who has OCD are 3 to 12 times more likely to develop this disorder. The younger the child is when they develop OCD, the more often they have a first-degree relative who is affected by OCD.

There’s limited research on how biology may play a role in OCD. Still, some brain imaging studies have revealed structural differences in the brains of people with OCD—more specifically, in the frontal cortex and subcortical structures, which are areas that help control emotional responses and behavior.

Studies have also found that OCD can be caused by “PANDAS,” or pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. This syndrome, which usually occurs between the ages of 3 and 12, can cause anxiety, tics, obsessions, compulsions, and changes in mood or personality. The key difference is that PANDAS symptoms typically show up very suddenly and rapidly, versus the gradual onset of OCD. Experts believe PANDAS is caused by the body’s faulty immune response to strep throat and Group A streptococcus infections.

Finally, some studies have suggested there may be a link between stressful or traumatic events—for example, a death in the family or a divorce—and early-onset OCD. 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. 

How is OCD treated in kids?

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. 

A specific form of behavioral therapy called exposure and response prevention (ERP) is considered the gold standard treatment for OCD.

Traditional talk therapy can actually be counterproductive, because when a child spends a lot of time verbalizing their fears out loud without actually confronting those fears, it can worsen their OCD symptoms. ERP, on the other hand, involves slowly and gradually exposing your child to their fears in a controlled environment while encouraging them to resist their compulsions. Over time, they realize that nothing bad happens when they don’t engage in their compulsions. By disproving their feared outcome, this approach reduces their anxiety and their need to resort to compulsions.

ERP was developed specifically to treat OCD, and research has repeatedly proven that it works very well for most people—even better than medication and other available OCD treatments. Several meta-analyses have found that ERP is highly successful at reducing symptoms of OCD in children and young people, specifically. After ERP treatment, roughly 70% of children and young people saw a significant improvement in symptoms, and 60% experienced full remission—meaning they no longer met the criteria for OCD. These benefits lasted long after treatment ended, too. 

Here’s how ERP works. A trained therapist who specializes in OCD will learn your child’s symptoms. Once they have an understanding of the obsessions and compulsions your child is experiencing, they’ll draw up an ERP therapy plan that’s customized to your child’s needs. The therapist will likely ask your child to rank their fears from mildest to most severe. From there, they will prompt your child to face a feared situation that typically triggers obsessive thoughts, and coach them through tolerating the discomfort rather than engaging in their compulsions. Rest assured, though, that the therapist will always start with a fear that your child ranked as causing only mild distress. Eventually, they will work with your child on tackling more distressing triggers. 

The exposures can happen in real life or in your child’s imagination. For example, a real-life exposure might entail having your child touch a doorknob, whereas an imaginal exposure might entail having your child draw that scene or act it out with plush toys or dolls. The therapist will also guide you through how to practice these exposures at home with your child in between sessions in order to achieve faster progress.

As a parent, it’s natural not to want your child to struggle—to feel worried or uneasy. But as Sirica puts it, OCD only offers short-term relief with long-term discomfort. ERP offers long-term relief with short-term discomfort.

“The amazing thing about this intervention is that it helps the child to retrain their brain,” says Sirica. “It teaches them to develop a different relationship with fear, and builds distress tolerance.”

You don’t even necessarily need to leave your home to try ERP. Virtual ERP therapy has made it easier and more convenient than ever to try this approach. And ERP teletherapy sessions are no less effective—in fact, peer-reviewed research has found that it can work even better and faster than traditional outpatient ERP therapy, offering results in as little as 12 weeks.