OCD Diagnostic Criteria: What are the signs of OCD in a child?
Everything you need to know about the symptoms of OCD – and when it’s time to seek OCD treatment for your child
Understanding the OCD Diagnostic Criteria is the first step to getting your child the help they need.
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Introduction
(Note: As with all clinical examples, I use fictional names and compile information from multiple clients to protect client confidentiality.)
One of the hardest parts of parenting a child with OCD is the very first step – identifying signs of OCD in your child. What makes this even harder for parents is that symptoms of OCD are sometimes missed among therapists and physicians, too. OCD treatment is not always a part of training for health care providers, so some might not recognize OCD symptoms in children or know how to treat OCD.
In my first meeting with Gretchen and her parents, I found out that she had seen several therapists over the years, but she had never received evidence-based treatment for OCD. Unfortunately, Gretchen’s symptoms of OCD had gotten worse and worse over time. While I was relieved that I was able to provide Gretchen with effective OCD therapy, it saddened me that it took so long for this teen and her family to get the help they needed.
The good news is that more and more health care providers are receiving training in OCD treatment in their graduate programs or through organizations like the International OCD Foundation, and there are ways for parents to empower and educate themselves about the signs of OCD, too. In this guide, you’ll learn all about how to detect OCD in kids and how to take the next step to bring your child and family relief.
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What are the signs of OCD in a child?
Parents are very intuitive of changes in their child’s behavior and the way they view the world. When I receive a call from a parent, they often tell me that they started seeing early signs of OCD from a young age and wondered whether this was typical child behavior or something different.
I’ve heard parents share, “I know a lot of children get anxious about their homework, but my son keeps checking his assignments over and over in a way I didn’t see with my older daughter.” Or, “I’ve noticed her touching the door in a certain spot every time she passes through – at first I didn’t think much of it, but then I started seeing it happen more and more, with different spots all over the house.”
Because there are different types of OCD, the signs can vary. But, as a parent, you want to look out for a couple things:
The first is obsessions – these are scary or irritating thoughts that get stuck in your child’s head and come up over and over again.
The second is compulsions – this is some sort of action your child takes or a routine your child follows, either in their mind or in their behavior – that brings some temporary relief when one of those intrusive thoughts comes up. We’ll go into this in a lot more detail in a moment as we walk through what determines a diagnosis of OCD.
One important thing is that signs of OCD might look different in children than you’d expect. For example, you might see oppositional or defiant behavior, like refusing to do something, or full-blown tantrums. Parents sometimes tell me, “It’s like she’s a whole different kid right now – she’s always been so well-behaved and mild-mannered, and now, there are times when she blows up over things, and I can’t tell what’s going on.”
Some kids have difficulty going to sleep or staying asleep, maybe because they have scary thoughts keeping them up or because a new routine has to be done in just the right way before they can go to sleep. Some children and teens will seem really unfocused and seem like they’re spacing out, at times not responding to their parents when they’re trying to talk to them.
Do these signs of OCD sound familiar to you? Now we’ll move into the next step – how to find out if a diagnosis of OCD is the right fit for your child.
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How is OCD diagnosed?
The first step in OCD treatment to make a diagnosis of OCD. Diagnoses for mental health conditions are a way for providers to communicate with one another and a way for your therapist to make a plan to provide the best care for your child.
To make a diagnosis, a trained mental health provider will use the criteria listed in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). This is a manual created by a group of mental health experts to help decide when a child’s thoughts, feelings, and actions are similar to other kids’ or when they’re outside the typical range and may require some help. They may use a structured OCD diagnostic test, either in interview form or one that you and/or your child will fill out on your own.
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What are the OCD diagnostic criteria?
Here are the criteria listed in the DSM-5 as to what qualifies as OCD. For each section of this OCD definition, I’ve included OCD examples to help these symptoms of OCD come to life.
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals can cause marked anxiety or distress.
Christine is a 9-year-old female who is really worried about getting her 4-year-old sister sick by bringing germs into the house. Christine has strong urges to wash her hands whenever she touches things in the house that she thinks might be dirty, and when she sees her little sister going to pick up a toy, she has an impulse to clean the toy before her sister touches it. She’s worried that, if she doesn’t keep herself and her sister 100% clean all the time, her sister is going to get sick and die.
Michael is a 13-year-old male who has a lot of habits that he can’t really explain. If he’s getting up from a chair and doesn’t feel like he did it in a certain way, he has an urge to do it again until it feels “just right.” The same thing happens when he’s trying to do his homework – if his writing doesn’t look “just right,” he’ll erase and rewrite it again until it does. Michael thinks that he has to do these things, or he’s going to feel so anxious that he won’t be able to handle it.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
In Christine’s case, she may try to push down her intrusive thoughts about her sister dying, or she may do what’s called neutralizing the thought by telling herself, “I don’t need to worry about her because I know I just cleaned that spot on the floor where she’s playing now.”
Michael tries to keep his anxiety from getting too high by repeating whatever he feels like he needs to do again until it feels like it’s done.
Compulsions are defined by (1) and (2):
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
A common picture of a person with OCD – one we’ve all seen in movies and TV shows – is someone who washes their hands a lot and likes to keep their house perfectly clean. And for Christine, washing her hands frequently and keeping her home clean were indeed part of her experience.
However, there were also actions that someone might not recognize right away as symptoms of OCD. Christine often engaged in what’s called avoidance, or finding ways to avoid coming in contact with something that she thought might lead to her sister getting germs on her. For example, Christine wouldn’t open her doors or drawers with her hands – she’d use her elbows, sleeves, or a paper towel, which helped her avoid getting germs on her hands.
She also asked her parents a lot of questions, something called reassurance-seeking. “Are you sure you didn’t touch anything dirty while you were driving home from work? Did you make sure to wash your hands before you made our dinner? Is my sister going to get sick because we played in the yard today?”
Michael does some of his habits over and over until they feel “just right.” At first, his parents didn’t notice them – a lot of kids check their homework, and they even liked that it seemed like he was being thorough and putting his best foot forward. Over time, though, they started to see that the habits were happening more and more, and they could see that they were taking up a lot of Michael’s time.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
It makes sense that Christine would wash her hands and avoid touching surfaces she thought were dirty to help prevent her sister getting sick. However, at a certain point, it started to become clear to her parents that her behaviors were excessive. Washing your hands for 20 seconds when you’ve touched something dirty is similar to what others would do; washing your hands for 5 minutes straight with 7+ pumps of soap starts to stand out from other kids.
In Michael’s case, some of the habits, like checking his homework, started to stand out when he checked his homework 5 times in great detail as opposed to the single check many students do when submitting an assignment. Other behaviors might seem very disconnected from something we’d think is important to reducing anxiety, like feeling the need to tap an object a certain number of times or needing to sit down in his chair in a very particular way.
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other areas of functioning.
Here, we think about how much living with OCD is making their life more difficult and getting in the way of their friendships, family life, and performance at school and other activities that are meaningful to them.
With all of her worries about germs, Christine was afraid to take part in activities she used to love, like playing soccer or having playdates with her friends. Her cleaning compulsions took so much time that it made her family members run late when they were trying to leave the house for school, which led to arguments between Christine and her parents. Some nights, Christine even skipped her shower altogether, because her shower routine was so long and specific that it felt really daunting to her.
Michael wasn’t really as bothered by his habits at first, but as they took up more and more of his time, they started getting in the way of things for him. He and his parents started arguing during homework time, because his erasing and rewriting made homework take a lot longer than it used to and wasted a lot of paper. Shortly before he started therapy, Michael got a few low grades because he never got to the point of feeling that his homework assignments were “just right,” so he didn’t hand them in at all.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or another medical condition).
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
I won’t go into these two DSM 5 OCD items in too much detail, but they are here for the purpose of making sure that providers don’t misidentify or double count symptoms. It’s certainly possible for children to have more than one mental health condition – when this happens, it’s called having two comorbid conditions. However, it’s important to make sure that the symptoms are being classified correctly so that a child gets the treatment that’s the best fit for him or her.
Let’s take Michael, for example. As I conducted my assessment, or my OCD diagnostic test, for Michael and his family, I asked some questions to see if a diagnosis of autism may be explaining what Michael was experiencing. Many children with autism have behaviors they repeat over and over, and they may like things like their toys or books to be a certain way or get angry when their routines are disrupted. You could see how this might look similar to the repetitive behaviors Michael did until it felt “just right.” By asking some clarifying questions, I was able to determine whether Michael fit for a diagnosis of OCD, a diagnosis of autism, or both.
Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
This part of the criteria helps providers and parents understand more about the child’s OCD thoughts, and it’s key to designing OCD interventions for children with intrusive thoughts.
Christine, for example, may tell me, “I know my sister probably isn’t going to get sick just from playing with a toy from her toy bin; I’m just worried about it, and I don’t really want to take the chance.” This would let me know that she had good insight.
On the other hand, Christine might tell me, “Of course, I have to shower every night for an hour, at least! That’s the only way I’ll know that I got all the germs off me. If I don’t, my sister is going to get sick and die, and it’s going to be all my fault.” If this was what Christine told me, I would know that she had poor insight, and helping her gain insight would be a part of our work together.
Specify if:
Tic-related: The individual has a current or past history of a tic disorder.
This last part is important because there are some differences in how OCD symptoms look and how they change over time in individuals with tic disorders. Tic disorders are common in children with OCD, with up to 30% of individuals with OCD having a tic disorder at some time during their life, and they’re particularly common in boys.
Do these criteria resonate with your experience? Does this sound like your child? Sometimes parents worry that receiving a diagnosis of OCD would be discouraging to their child and would make them feel labeled or different from other children. And certainly, it can be a lot for children and families to process.
However, much more often, I find that children and families find relief and clarity from the diagnostic process. A child who has been hiding blasphemous thoughts may be relieved to learn that he’s not the only one with religious OCD symptoms (much more about this in my Scrupulosity OCD guide). A teenager can finally make sense of why she feels like she has to do odd habits that none of her friends do. Rather than discouraging, the assessment process often feels therapeutic and hopeful for children with OCD and their parents.
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Frequently Asked Questions
(Note: The therapeutic techniques described in this section are for educational purposes only and do not constitute advice or therapeutic recommendations. Don’t try these techniques on your own, but please contact me or another qualified provider if you’re interested in learning about how OCD treatment could help you or your child.)
Don’t a lot of kids like routine, or for things to be done a certain way? How do I know when it’s normal kid behavior, and when should I be concerned about my child’s anxiety?
Yes, routines are certainly common during childhood and adolescence, and for many kids and families, routines can provide structure that is helpful for getting enough sleep, getting to school on time, and so on. The “repetitive behaviors” described in the OCD diagnostic criteria are different – these are typically very specific and rigid, and you’ll see a lot of stress or even a temper tantrum if they’re disrupted.
When a parent asks me this question, I encourage them to try changing up a routine slightly and seeing what happens. For example, if a child usually wants her father to say, “I love you” 3 times as he leaves home for work, the father may try saying, “Love you, sweetie!” just once. If a child usually requests that his mother kiss his teddy bears in a certain order before bedtime, the mother may try kissing a different teddy bear first or skipping the kisses altogether.
While many children may protest, most will move on pretty quickly. Others, however, may become really upset, and they may insist, yell, or bring up the changes to the routine over and over the next day. If disrupting the routine causes a big issue for your child, it may be a sign of OCD that could benefit from further assessment with a mental health provider.
I could see how normally it’s not a good idea to wash your hands too much or to avoid touching things, but in the time of COVID-19, doesn’t this make sense? Isn’t contamination OCD kind of a good thing right now?
COVID-19 has undoubtedly increased stress across the board, including for children living with OCD. For children with harm OCD, some have noticed an increase in intrusive thoughts about hurting vulnerable family members like grandparents by accidentally exposing them to COVID-19 while asymptomatic (learn more in my Harm OCD Guide). Parents of children with contamination OCD may notice them washing their hands more frequently, wiping down surfaces all over the home, avoiding leaving the house, or asking their parents repeated questions about their health and safety. With increased stress all over the world and mixed messages about what’s involved in staying safe, it makes sense we’d see more of these behaviors!
What’s important is to stay within trusted health guidelines and to not go above and beyond this. For example, the Centers for Disease Control and Prevention (CDC) guidelines for handwashing instruct us to use soap and water for 20 seconds to wash our hands when we return home after being in a public place. They do not instruct us to shower for 30 minutes or re-sterilize our entire home after we enter our home after being in our own backyard.
While it is certainly important to remain safe during this challenging time, it’s also important for children living with OCD to establish behaviors and precautions based on facts rather than on what OCD may be telling them to do. If you’re unsure about how to strike this balance and how to talk to your child with OCD about COVID-19, check out these helpful COVID-19 resources from the International OCD Foundation.
Conclusion
For too many children living with OCD, it takes years to get the treatment they need, as many parents, teachers, mental health providers, and children themselves might not recognize OCD symptoms at first glance. Fortunately, OCD awareness is increasing, and more and more resources are becoming available to bring understanding for OCD in children. If this guide resonated with you, let’s take the first step together to getting your child the help they need.