OCD in children: when a ritual is a developmental phase and when it is a sign

A five-year-old cannot fall asleep until the teddy bear is on the left, the rabbit on the right, and the door is ajar by exactly the width of a hand. Then you have to say “good night, sweet dreams” three times — and if you get the words wrong, you both start again. Most evenings you find it endearing. On some evenings, when you are tired, a thought crosses your mind: is this still normal?

It almost always is. Rituals are one of the ways small children tame a world that is big and unpredictable to them. But precisely because they are so ordinary, parents find it hard to spot the rare cases when a ritual is no longer a developmental phase but a sign that something is troubling the child. And the reverse: because obsessive-compulsive disorder is talked about so much today, many a parent takes fright at perfectly ordinary behaviour.

In this post I would like to help you tell one from the other — not so that you can diagnose at home, but so that you know when to wait calmly and when to talk to your child’s doctor.

Rituals are part of growing up

Researchers at Yale University asked almost 1,500 parents how often their children insisted on an exact sequence, on things being “just right”, or on always the same food and clothes. It turned out that this kind of behaviour is most common between the ages of two and four and then gradually declines (Evans et al., 1997). In other words: the two-year-old who bursts into tears because you cut the bread “wrong”, and the three-year-old who has to press the lift button herself, are developmentally exactly where they should be.

These rituals have a job to do. A small child has very little control over their day, so they create it where they can: in the bedtime sequence, in the arrangement of toys, in rules they set themselves. The evening ritual is also a bridge across the separation from parents — which is why it often intensifies at times when separation anxiety is more pronounced, when a sibling is born, when the family moves or when nursery begins.

In school-age children, rituals change rather than disappear. Collections appear, games with strict rules, “lucky” objects before a match and small superstitions such as avoiding the cracks in the pavement. All of this is part of ordinary development. The child enjoys these things, uses them to connect with peers, and drops them without much harm when something more interesting comes along.

What is different in OCD

Obsessive-compulsive disorder is a mental disorder in which intrusive, unpleasant thoughts or doubts (obsessions) cause intense anxiety, and the child tries to reduce it with repeated actions or mental rituals (compulsions). How this loop is built in adults is described in Obsessive-compulsive disorder: more than tidiness and cleanliness. Among children and adolescents, professional estimates put it at around 1 to 2 per cent (Geller & March, 2012) — so it is not common, but it is not extremely rare either.

From the outside, a ritual in OCD can look almost the same as a developmental one. The difference lies in what drives it and what it does to the child’s day. Clinicians look mainly at four things.

• The feeling. A developmental ritual brings the child satisfaction or calm. A ritual in OCD brings only brief relief; the child is tense while doing it, often close to tears.
• The reaction to interruption. If you interrupt a developmental ritual, the child protests and is distracted a few minutes later. In OCD, interruption triggers real panic, and the ritual has to be started again until it is “right”.
• Time and growth. Developmental rituals are short and stay roughly the same. In OCD, new rules are added and the ritual takes more and more time; as a guide, the diagnostic manual mentions more than an hour a day (American Psychiatric Association, 2013).
• Interference. The child is late for school, cannot get to sleep, avoids friends or places, and homework takes hours because they rub out and rewrite.

None of these signs on its own means a disorder. What matters is the pattern: several signs at once, lasting for weeks and not settling when a stressful period passes.

What it looks like at home

Parents rarely see the obsession — it is in the child’s head. They see the consequences. Hands that are red and cracked from washing. A very long time spent in the bathroom. A laundry pile that suddenly grows because a piece of clothing is “dirty” after one touch. Exercise books worn through from rubbing out. A child who goes back through the door until they have stepped through it “right”, or who has to touch something equally with the left hand and the right.

Questions are a form of their own. “Are you sure I won’t get ill?” “Nothing’s going to happen to you, is it?” “Did I say something nasty?” Every child asks something like this now and then. In OCD, however, the same question comes back ten times a day, the answer calms only for a moment, and the child sometimes demands that you say it in exactly the same words. “Confessing” belongs here too: the child has to tell you every “bad” thought in order to feel better.

The content of children’s fears is often tied to what matters most to them: that something will happen to their parents, that they will fall ill, that they will accidentally hurt someone or that they have done something wrong. I have written about why such thoughts say nothing about character in Intrusive thoughts: why you have thoughts that frighten you — and why they are not your character. For a child this is even harder to grasp than for an adult.

Why the child doesn’t talk about it

Many children hide their rituals. Older children and teenagers often know that what they are doing is odd, and they are ashamed. So they perform their rituals when nobody is watching, hold themselves together at school with all their strength, and fall apart at home. What parents then see is mostly irritability, outbursts of anger and lateness — and they read it as stubbornness.

Younger children, on the other hand, often cannot say at all why they have to do something. They only say that “it has to be like this”, or that otherwise “something will happen”. We expect an adult to recognise their fears as excessive; we cannot expect that of a seven-year-old.

That is why it helps to ask without judgement and without interrogating: “I notice you wash your hands for a very long time. Is something in your head telling you that you have to?” Simply having permission to say it is often a relief for the child. In treatment with children, therapists often give the disorder a name or a nickname so that the child can separate it from themselves more easily: the child is not “naughty” or “weird”; something is pestering them, and it can be stood up to together.

Comfort, yes; joining the ritual, no — but carefully

When a child is frightened, a parent comforts them. That is right and must stay that way; a child learns to settle alongside an adult, which we call co-regulation. The difficulty begins when comfort becomes part of the ritual: when you answer the same question for the twentieth time, when you check on the child’s behalf, wash their clothes after every touch, or the whole family moves around the house by their rules. Clinicians call this family accommodation, and it is very common among families of children with OCD — because no parent can calmly bear their child’s distress.

“Mummy, did you wash your hands before you touched my pillow?”
“I can see that’s really worrying you.”
“Just tell me. Did you or didn’t you?”
“I’ve already told you once. I think that fear is pestering you again. Shall we wait together for it to pass?”
“What if it doesn’t?”
“Then I’ll still be here. The fear is loud, but it isn’t the boss.”
(composite, not a real person)

A conversation like this is a destination, not a starting point, and parents usually get there with professional support. The distinction worth remembering is this: you comfort the child (a hug, closeness, “I can see this is hard for you”), but you do not answer the fear over and over again. The opposite extreme is dangerous too. If you withdraw overnight everything you used to do, you leave the child alone with something they cannot manage. Punishment, mockery and arguing with logic do not help; a child cannot give up a ritual just because you tell them to.

So the rule is: accommodation is reduced gradually, by agreement, and ideally under the guidance of the professional treating the child. That work with parents carries real weight is shown by a Yale study of 124 children with anxiety disorders: a programme in which therapists worked only with the parents — teaching them supportive responses and how to reduce accommodation — was comparably effective to cognitive behavioural therapy with the child (Lebowitz et al., 2020). The study covered anxiety disorders rather than OCD specifically, so it should not be over-generalised, but the message is encouraging: how you respond counts.

Exercise: a week of observation

Before you change anything or ring anyone, observe for a week. The notes will be useful to you, so that you see more clearly, and to the doctor, should you decide on a visit.

1. Choose one behaviour and describe it in facts. Not “he was at it again”, but: “Before bed he checked six times whether the window was shut.”
2. Measure the time. How many minutes it takes and how many times a day it is repeated. A guess from memory is almost always wrong — in one direction or the other.
3. Note the child’s feeling. Were they content, absorbed, calm during the ritual? Or tense, frightened, close to tears? What happened when the ritual was interrupted?
4. Note your own part. Did you answer questions, wait, check for them, change the plan for the day? No self-blame — simply as information.
5. After seven days, read it all through. If the rituals are short, the child is not distressed by them and the day runs, carry on watching calmly. If they take more and more time, trigger panic or shape family life, take your notes and make an appointment with your child’s doctor.

Where to go for help

The first port of call is your child’s own doctor — a paediatrician or school doctor. They assess the child’s general health and decide whether a referral is needed. A diagnosis of OCD is made by a child psychiatrist or a clinical psychologist; in Slovenia, this kind of help is also offered by the centres for the mental health of children and adolescents attached to community health centres. Which professional does what is explained in Psychotherapist, psychologist, psychiatrist: who does what and where to go.

The treatment recommended by professional guidelines is cognitive behavioural therapy with exposure and response prevention, adapted to the child’s age; in more severe forms the child psychiatrist also considers medication (Geller & March, 2012). In a well-known American trial with children and adolescents, both the therapy and the medication did better than placebo, and their combination did best (POTS Team, 2004). For young children aged five to eight, a form of therapy in which parents take part throughout proved effective (Freeman et al., 2014). To be clear: I do not provide this treatment, and I do not work individually with minors.

One circumstance calls for a quicker response. If rituals, severe fears or tics appear very suddenly, almost overnight, in a child who did not have them before, see the paediatrician as soon as you can. Some researchers link such a sudden onset to infections, for example streptococcal ones (Swedo et al., 1998); the area is still a matter of professional debate, which is exactly why a doctor’s judgement is called for.

With a teenager who refuses help, the steps are somewhat different; that is the subject of When to take a teenager to a therapist: signs, routes and what if they refuse.

When the answer lies elsewhere

This post could be read as a list of reasons to worry, so let me say the opposite as well. The great majority of children’s rituals are not OCD. A child who always wants the same cup, who sorts toy cars by colour or who wears only one T-shirt for three months is, in the vast majority of cases, simply a child.

Even when rituals are more marked, the explanation may lie elsewhere. In stressful periods many children’s rituals intensify for a while and ease by themselves once life settles. Repetitive behaviours can be part of a more general anxiety — which is covered in Anxiety in children: how to recognise it and how to help. Some children have tics that look like compulsions from the outside but are not driven by fear. Autistic children often have routines and repetitive interests that bring them pleasure, not distress. Telling all of this apart is a professional’s job, not that of a parent on the internet — and not mine in a blog either.

One more thing: if your child does have OCD, you did not cause it. The disorder is not the result of upbringing, or of too much or too little order at home. Having gone along with their rituals is the response of a loving parent, not a mistake to be paid for in guilt.

Where family therapy fits in

A child’s OCD is a trial for the whole family. Parents often diverge in their approach — one gives way, the other holds firm — and argue about it more than about anything else. Siblings get less attention and more rules. Everyone is tired.

Treatment of the disorder is led by a child psychiatrist or a clinical psychologist. Family therapy does not replace it, but it can complement it: it is a place where the parents get on the same page, where a sibling has a say too, and where you can say how hard it is to watch your child in distress and not give them what they are asking for. In relational family therapy we are interested in how each person in the family carries their share of this burden. Sessions take place in person in Ljubljana, and I also work with English-speaking families. If the person close to you with OCD is already an adult, When someone you love has OCD: how to help without taking part in the rituals was written for you.

What to remember

• Rituals are developmentally ordinary between the ages of two and four and give a child a sense of safety; in school-age children they turn into collections, rules and small superstitions.
• What points to OCD is a pattern: fear drives the ritual, interruption triggers panic, rules multiply, the day is disrupted — and it lasts for weeks.
• Comfort the child, but do not answer the fear over and over. Do not stop accommodating overnight, and never as a punishment.
• The first step is a conversation with the paediatrician or school doctor; a child psychiatrist or clinical psychologist diagnoses and treats.
• OCD is not the result of upbringing. Your task is not to treat it but to notice, to find help and to stay beside your child.