OCD in Children: Guidance for Parents

Written by Dr Lucy Russell DClinPsyc CPsychol AFBPsS
Dr Lucy Russell Founder of They Are The Future
Author: Dr Lucy Russell, Clinical Psychologist

Perhaps you have noticed signs of OCD in your child? In this article I will talk about what OCD in children looks like.

I outline the most effective treatment options and to help you consider what will help your child recover from OCD.

Symptoms of OCD in Children

The symptoms of OCD are intrusive, persistent thoughts, accompanied by repetitive physical rituals or mental acts related to the intrusive thoughts.

Compulsive rituals might include – for example – excessive hand washing, or bedtime rituals such as saying goodnight a certain number of times. These thoughts and rituals are associated with powerful emotions such as anxiety and fear.

OCD Symptoms in Children: Spotting the Early Signs

Early signs of childhood OCD can be difficult to spot, because it is very common for children to have physical and mental rituals or habits.

It can be a part of normal development.

Often, we engage in rituals to help us feel safe or in control.

For example, your child may feel they need to arrange their teddies in a certain way before they can go to sleep, or have a certain way of saying goodbye to you before school each morning.

However, a diagnosis of OCD is only given if the unwanted thoughts and repetitive behaviors are having a significant negative impact on a child’s quality of life.

What Age Does OCD in Children Affect?

Obsessive compulsive disorder can occur in preschool children right through to older children and adults.

close up of a little girl looking into the camera

Often the obsessive thoughts are fears that something bad will happen to a loved one or to the child themselves.

The rituals become linked to the thoughts, as ways to try to stop the bad thought coming true.

For example: A child may feel they have to wash their hands twenty times, to prevent them contaminating family members with germs from dirty objects.

Types of OCD Rituals in Children

Sometimes the rituals are mental rituals so you don’t see them. This might be saying certain words over and over in a child’s head for example, to “neutralize” a fearful thought.

Other times the OCD rituals are verbal or physical.

An example of a verbal ritual is having to say a phrase out loud whenever the child has a trigger thought.

Children may be doing physical rituals overtly, or they may be masking them.

For example, if a child is engaging in physical rituals at school under the desk (e.g. tapping each finger on the knee twenty times), the school may be unaware that the child is experiencing OCD.

The OCD Cycle

OCD rituals relieve or neutralize the obsessive thoughts or fears, making the child feel better. Sadly this only lasts a short while, until the fear or bad feeling comes back.

This creates a vicious cycle.

OCD in Children: The OCD cycle

Rituals can (and often do) evolve.

One may fade away to be replaced by another one.

OCD can be exhausting and depressing. It can feel like you can never switch off, or that your brain has been invaded.

In this video, children explain how their OCD affects them:

YouTube video

OCD in Children: Case Examples

If you can relate to what I have written in this article so far, you may still be wondering if your child’s difficulties are severe enough to warrant a diagnosis of OCD.

The DSM-V (Diagnostic and Statistical Manual, Version 5) states that for a diagnosis to take place:

The obsessions and/or compulsions cause marked distress, are time consuming (take more than 1 hour per day), or interfere substantially with the person’s normal routine, occupational or academic functioning, or usual social activities or relationships.

The full diagnostic criteria for OCD are listed in this article by OCD UK.

Here are some case examples of OCD in children to guide you further. These case examples are not real children, they are based on some of the children I have worked with over the years as a clinical psychologist with school-aged children.

OCD in Children: Case Example (Reuben)

Six year old Reuben worries about saying a bad word or thinking a bad thought.

Every time he thinks he said a bad word or thought a bad thought, he has to say “Sorry” 5 times.

If Reuben doesn’t say sorry 5 times, he becomes extremely distressed and will have a meltdown.

Reuben’s distress and meltdowns are severely affecting both school life and daily living at home.

OCD Symptoms in Teens: Case Example (Gemma)

Fifteen year-old Gemma is terrified of bringing home germs from school that will make her mum ill. Her mum has asthma and is in remission from breast cancer.

Gemma has a lengthy ritual when she gets home from school. She has to wash her hands for a minimum of ten minutes, then put every item of clothing in the washing machine and shower herself.

She leaves her school bag in the porch and will not bring her school books into the house in case they are contaminated.

Gemma has stopped going out – other than to school – because she finds her extreme preoccupation with germs and compulsive behaviors so exhausting.

unhappy anxious teenage girl

Signs of OCD in Children: Aston (Case Example)

Nine year-old Aston has many fears about bad things happening. He has developed mental and physical OCD rituals to try to protect himself throughout daily life.

There are many things which he believes bring bad luck.

For example, if he sees a yellow car he has to say “yellow car” in his head over and over until it “feels right”.

At bedtime his parents must say goodnight in a certain way otherwise he believes it is bad luck. They must say “good night, love you, sleep tight”. Then he must say “good night, love you”. If it has said in the wrong order, they must start again.

Aston’s teachers have begun to notice that he is “zoned out” at least 50% of the time in lessons, because he is busy performing the OCD mental rituals in his head.

Aston’s anxiety permeates his whole life.

anxious little boy, head in hands

Causes of OCD in Children

There is no single cause of OCD in children. Often though, it starts when a child has faced an event where they felt out of control.

This could be anything from bereavement to moving house or bullying.

The brain has tried to find a way to help the child feel in control again, and the rituals have served this purpose.

Also, it commonly emerges during times in a child’s life when they may be struggling with the idea of increased responsibility in their lives and daily activities.

OCD may start gradually and gather momentum, or it may have a sudden onset. When there is a sudden onset, it may be caused by a change in environment or circumstances (such as moving to secondary school) but there is also a growing body of health professionals who believe the symptoms can be brought on by an infection (see PANS/PANDAS section below).

Outsmart Anxiety online parent course

OCD Treatment For Children

The great news is that psychological treatment for children with OCD tends to be very effective, as long as it is offered by a mental health professional with a high level of training and experience, such as a clinical psychologist.

Early treatment is vital, as OCD can quickly escalate.

The most effective treatment option for OCD, which is recommended in the UK by NICE (the National Institute for Health and Care Excellence) is called ERP: Exposure and Response Prevention.

ERP comes under the umbrella of CBT (cognitive behavioral therapy).

The treatment process for OCD tends to be more structured and focused than for other types of mental health condition.

How to Help a Child with OCD: ERP Explained

In ERP (Exposure and Response Prevention) the child or teenager with OCD will gradually make their way up a “hierarchy” of steps to overcome their OCD.

In each step they are gently “exposed” to the fearful thought or condition, and they reduce their rituals gradually.

For example, if a child is washing their hands 50 times per day, a treatment plan may involve gradually reducing the maximum number of times they wash their hands each day. They may aim for 48, then 45, and so on.

The child or teen with OCD must feel in control. The pace is dictated by the child themselves.

anxious tween girl leaning against a wall

For Gemma, my case study above, she might work towards reducing the length of her rituals and the number of times she repeats each part.

There are other important aspects of ERP therapy, such as measuring progress along the way and ensuring the child has new ways to manage the big feelings of anxiety during treatment.

Parents must play an active part in the treatment.

ERP is a particular technique drawn from CBT (cognitive behavioural therapy). ERP focuses more on the behaviours than the thoughts, but sometimes a therapist will work on gently adapting the fearful thoughts too.

OCD in Children: “Externalising” as a Therapeutic Tool

In therapy for OCD in children and teenagers with OCD, therapists often use a technique from narrative therapy called externalising. Therapists should use externalising as an adjunct to ERP, not as an alternative.

Externalising can be really helpful because it involves naming the OCD as though it were a character. This helps the child see that OCD is not a fundamental part of them.

For example, OCD is often referred to as a bully, as it can make us do things we don’t really want to do.

This allows parents, professionals and the child to “team up” and stand up to the bully.

OCD in Children: The OCD Bully (Externalising Technique)

OCD in Children: Medication

If a child’s OCD is severe, a doctor (usually a child psychiatrist) may prescribe medication.

This is usually a medication called SSRI – selective serotonin reuptake inhibitor.

Studies show that SSRI’s can be effective in treating OCD. They are also widely used to treat other psychiatric disorders such as depression.

Sometimes in severe cases, medication and psychological treatment together have the best outcome.

You can read more here.

OCD in Children: PANS/PANDAS

Have you heard of PANS or PANDAS?

In recent years, links have been increasingly discovered between medical conditions and mental health disorders. Sudden onset OCD has been linked to streptococcal infections (also known as strep throat), which can be treated with antibiotics.

PANS stands for pediatric acute-onset neuropsychiatric syndrome, and PANDAS stands for pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections. PANDAS is a sub-group of PANS.

PANDAS is thought to be an over-reactive immune response to the strep bacteria.

In the UK, PANS and PANDAS are not universally accepted or recognised by health professionals. But if your child’s OCD symptoms and severe anxiety came on very suddenly (within 48 hours), you should discuss this with your doctor.

You can read more in this Complete Guide to PANS and PANDAS.

happy boy at school sitting at desk

What Support Resources Are Out There?

The children’s workbook Think Good, Feel Good by Paul Stallard is a CBT-based guide full of helpful explanations and worksheets for children to complete. Younger children will need help from their parents or their therapist/psychologist.

OCD-UK’s website has lots of resources including articles written by it’s Young Ambassadors.

Get Self Help is a psychology-based website where you can learn about techniques to support a variety of mental health conditions. It has  a page on OCD which could be helpful for parents (in helping their children) or for teens to look at.

What to Do When Your Brain Gets Stuck: A Kid’s Guide to Overcoming OCD is a book written by Dawn Huebner and Bonnie Matthews. It’s a cognitive-behavioural self-help book aimed at age 7 plus.

Breaking Free of Child Anxiety and OCD A Scientifically Proven Program for Parents by Eli R. Lebowitz is a complete parent-led treatment programme for OCD in children and young people. In this book you will learn how to respond to your child’s OCD in the most effective way.

TAKE THE QUIZ!

OCD in Children: Does My Child Need Professional Help?

Parents often ask me how to tell if their child has reached a stage where they need professional help for OCD. 

It’s quite common for children to have some obsessive thoughts and rituals, and you shouldn’t automatically panic if you spot some. These may fade over time.

Only if you have noticed a negative change in your child’s well-being and/or this is impacting on day-to-day life do you need to seek help for OCD. Talk it through with your family doctor or another health professional.

If you are struggling to find help for your child’s OCD symptoms, get started with some of the self-help resources I have listed above, and keep trying to get your child assessed or onto a waiting list at the same time. In the UK, your child’s school can make a referral to children’s mental health services as well as their GP (general practitioner).

How to Help a Child With OCD at Home: 5 Tips

  1. Don’t get angry. A child with OCD has a very high underlying level of stress. They need you to be as calm and patient as you can, otherwise you could increase their stress and inadvertently make the condition worse.
  2. Be careful of “colluding“. Sometimes parents end up colluding; going along with the rituals themselves. A child will tell a parent they have to say a certain phrase three times for instance. Do be aware of this and try to resist collusion if you can.
  3. Reduce stress wherever possible. Are there areas of your child’s life where you can reduce stress for a while? High stress can worsen OCD. Perhaps you can remove some responsibility from them temporarily, e.g. asking the school if home work could be reduced?
  4. Teach your child about OCD. One of the best things you can do for your child is to help them understand what OCD is and how it works. This can help them to feel less alone and more in control of their condition.
  5. Seek help early: OCD can spiral quickly. It is a highly treatable condition and responds well to ERP (exposure and response prevention) treatment.

Further Reading

Autism Vs OCD: Understanding Your Child

5 Emotional Regulation Activities For Children

Phobia: Supporting Your Child

Helping Teens With Anxiety

Take a look at my online course for parents, Outsmart Anxiety.

Dr Lucy Russell is a UK clinical psychologist who works with children and families. Her work involves both therapeutic support and autism assessments. She is the Clinical Director of Everlief Child Psychology, and also worked in the National Health Service for many years.

In 2019 Lucy launched They Are The Future, a support website for parents of school-aged children. Through TATF Lucy is passionate about giving practical, manageable strategies to parents and children who may otherwise struggle to find the support they need.

Lucy is a mum to two teenage children. She lives in Buckinghamshire with her husband, children, rescue dog and three rescue cats. She enjoys caravanning and outdoor living, singing and musical theatre.

To learn more tips for helping your child manage stress, join my Facebook group, Parent Tips For Positive Child Mental health UK.

parent tips for positive mental health facebook group