Guide to OCD diagnosis and treatment in children and teens

Maybe your child asks the same question ten times before bed and needs the exact same answer each time. Maybe they told you, in tears, about a thought that scared them. OCD (obsessive compulsive disorder) in children is often missed, and it can be treated^{[1, 6]}. This guide explains what OCD looks like in children and teens, how it differs from ordinary habits, and what treatment actually looks like.

What is OCD in children?

OCD is associated with distressing unwanted thoughts, images or urges, and feeling pushed to repeat actions or mental habits (compulsions), which bring only brief relief from the distressing thoughts^[1]. One research review estimates that 1 to 3 percent of children and teens have OCD^[5].

Obsessions are thoughts, urges or mental images that are intrusive, unwanted, and make most people anxious^[1]. Compulsions are repeated behaviors a person feels the urge to do, often in response to an obsession^[1]. Checking that a door is locked, washing, arranging things just so, and praying or repeating words silently are all common compulsions^[1].

Children often experience OCD differently from adults^[1]. Many adults with OCD know their rituals do not make sense^[1]. Children, though, may not realize their behavior is out of the ordinary, and they often fear that something terrible will happen if they skip a ritual^[1]. Children are also less able than adults to put their obsessional thoughts into words^[6]. Parents or teachers are typically the ones who recognize OCD symptoms in children^[1]. You can read more about how I evaluate and treat OCD.

Why is OCD in kids so easy to miss?

OCD can be easy to miss because some rituals are done silently^[1] and some look like ordinary childhood routines^[6]. A child may seek reassurance, avoid certain places, count, or pray silently^{[1, 3]}. In my experience, families often adjust around these habits without recognizing them as OCD, so the problem can seem to appear suddenly.

When most people think of OCD, they might imagine repeated handwashing or repeated flipping of a light switch. In my practice, I often see signs that are less obvious. They can include:

• Asking a parent the same question again and again ("Are you sure I won't get sick?") and needing a specific answer repeatedly
• Confessing small things, or needing to tell a parent about every "bad" thought.
• Silent rituals, such as praying or repeating words silently, or counting^[1].
• Avoiding places, people or objects that trigger a fear^[1].
• Bedtime or getting-ready routines that must be done "just right," with distress if they are interrupted.

Children may also keep their symptoms to themselves^[6]. People with OCD may not tell their health care provider about their obsessions and compulsions out of fear of judgment^[1]. Symptoms can start slowly and often get worse during times of stress^[1].

Help often comes late. One research review describes an average gap of more than two years between when OCD starts in children and when it is diagnosed^[6]. Many families I work with tell me the problem appeared "out of nowhere." When we look back together, the signs were often there for months, quietly folded into family routines.

One exception deserves its own note. PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections) is a condition in which there is sudden and severe onset of OCD or restrictive eating in a child before puberty^[2]. In the case of PANDAS, OCD symptoms can reach full intensity within a few days^[2]. A change that fast warrants prompt medical evaluation, not a wait-and-see approach. You can learn more on my PANS and PANDAS page.

Are intrusive thoughts a sign my child wants to do something bad?

No. In my experience, intrusive thoughts are not wishes. In OCD, a child may have unwanted thoughts about harming someone, or upsetting thoughts about sex or religion, and these thoughts make them feel extremely anxious^[1]. What I see is that the distress comes from the fact that the thought feels so wrong to the child, which is the opposite of genuinely wanting it.

According to the NIMH, the most common obsessions include aggressive thoughts toward others or oneself, and unwanted, taboo thoughts about sex^[1]. Compared with adults, children and teens with OCD more often have obsessions about catastrophes, such as fears that they or someone they love will die or get sick^[5].

These thoughts can be hard to talk about. Children may feel ashamed of them, and thoughts about sex or hurting someone can make children feel guilty and keep them from telling anyone^[6]. Compared with adults, children may lack the words to describe what is happening to them^[6].

If your child tells you about a thought like this, here is what I suggest:

• Stay calm, and thank them for telling you, and remind them they can always talk to you.
• Avoid asking them to explain or prove why they would never act on it.
• Let them know that there are people who can help them with these thoughts and feelings.

I find that naming these thoughts as part of OCD reduces shame, for children and for parents, and makes it easier to talk about them openly. Thoughts about wanting to hurt oneself, or about not wanting to be alive, are different. Always take these seriously. If your child says something like that, call or text 988 or 911 and contact their doctor.

How do families get pulled into OCD?

Family accommodation is when parents take part in a child's rituals, answer repeated reassurance questions, change routines, or help a child avoid triggers^[5]. Families do this to ease the child's distress^[5]. It comes from love. Over time, though, it can reinforce OCD and help keep it going^[5].

The goal of therapy is to help the child learn that the feared outcome usually does not happen. Accommodation, even though it is often well-intentioned, can often prevent this goal^[5]. Higher levels of accommodation are associated with more severe OCD symptoms, more impairment, and poorer treatment outcomes^[6]. This is not a parent's fault. In my experience, most families slide into accommodation gradually, one reasonable-seeming answer at a time.

I do not recommend stopping all at once. When a parent refuses to go along with a ritual, a child with OCD may react with anger or outbursts^[6]. NICE (the National Institute for Health and Care Excellence, which writes UK health guidelines) says treatment should help family members step back from rituals, avoidance and reassurance seeking "in a sensitive and supportive manner"^[3]. In family-based treatment, parents learn how to reduce accommodation, help with ERP practice, and cope with their own worry^[6].

Is it OCD or a normal childhood ritual?

Many childhood rituals are normal. Young children often have bedtime routines, mealtime routines or small superstitions that fit their age^[6]. I recommend an evaluation when a habit causes significant distress, takes more than an hour a day, or causes significant problems in daily life^[1].

Everyone double-checks things sometimes, and not every ritual or habit is a compulsion^[1]. Ritual-like behavior in children typically starts to decrease from about age 7^[6]. The right column below follows how NIMH describes OCD^[1]. The left column is general guidance.

What does OCD treatment for children actually look like?

The main therapy for children with OCD is cognitive behavioral therapy (CBT) that includes exposure and response prevention (ERP)^{[3, 5]}. The NICE guideline recommends adapting it to the child's age and involving parents^[3]. Medication, usually an SSRI, may be added when OCD causes moderate to severe impairment and CBT with ERP has not helped enough^[3].

Exposure and response prevention: ERP is a type of therapy where a child practices facing a fear (obsession), step by step, without doing the associated ritual (compulsion)^[1]. It can feel uncomfortable at first, but compulsions decrease for most people who keep going^[1]. CBT with ERP as its core is the most established psychological treatment for OCD in children and teens^[5].

Parent involvement: Parent involvement is especially important for younger children^[5]. In the POTS Jr trial, 127 children ages 5 to 8 received either family-based CBT with ERP or a family-based relaxation program^[4]. After 14 weeks, 72% of children in family-based CBT were much or very much improved, compared with 41% in the relaxation program^[4]. Parents took part in every phase of treatment, and children learned to treat OCD as something separate from themselves^[4]. The researchers concluded that young children with OCD warrant "more than a 'watch and wait' approach"^[4]. In the POTS Jr program, ERP was tailored to each child's developmental level and built from gradual steps, with parents actively involved^[4]. With teens, I find the work is more collaborative, and they help choose the steps.

Medication. SSRIs (selective serotonin reuptake inhibitors) are considered the first-line medication option for OCD in children and teens^[6]. NICE says that for children ages 8 to 11 with moderate to severe impairment from OCD that has not improved enough with family-involved CBT, adding an SSRI may be considered^[3]. For teens ages 12 to 18 in the same situation, it should be offered^[3]. When an SSRI is used, it should be combined with ongoing CBT with ERP^[3]. It can take up to 12 weeks to see the benefit^[3].

Antidepressants, including SSRIs, carry an FDA boxed warning: in short-term studies, they increased the risk of suicidal thoughts and behaviors in children, teens and young adults^[8]. Prescribers are told to monitor closely, and the first few months of treatment and any dose change are times to watch especially carefully^[8]. Never start, stop or change a medication without talking with your child's prescriber.

As a psychiatrist, my role is to make the diagnosis carefully, separate OCD from conditions that can look like it, and work alongside the ERP therapist. I prescribe medication when it is clinically needed and when the family wants it, and I adjust the plan together with parents and the child.

When should I get my child evaluated for OCD?

Consider an evaluation if a worry or habit causes your child significant distress, takes more than an hour a day, or causes significant problems in daily life^[1]. You do not need to wait until things are severe. A longer stretch of untreated OCD is associated with more disability and more family accommodation^[6].

Other reasons to reach out sooner:

• Your family's routines have started to bend around your child's fears or rituals.
• Your child is scared of their own thoughts, or keeps confessing them.
• Symptoms appeared suddenly, over a few days^[2]. This needs prompt medical evaluation.

An evaluation starts with a careful medical history, including family history, and a physical exam^[7]. It also includes interviews and rating scales^[7]. A clinician will ask about repeated rituals, things your child avoids, and unwanted thoughts^[7]. In my practice, the evaluation has two parts. I meet with parents first, so you can share the full history, and then I meet with your child.

Treatment helps many people with OCD, even those with the most severe forms^[1]. In my experience, with the right support, children can learn that their thoughts are not dangerous, and families can step out of the cycle together. If you are in Brookline or the Boston area and have questions about your child, you can learn more about my child and adolescent psychiatry practice.