Obsessive-compulsive disorder (OCD) is a common neuropsychiatric condition that features a pattern of uncontrollable obsessions and/or compulsions that interfere with normal functioning and cause major distress.

Roberto Olivardia, Ph.D., a clinical psychologist specializing in treating ADHD and OCD, describes obsessions as recurring, unwelcome thoughts, impulses or images that “hijack” the mind and cause significant anxiety, distress, or fear. They are not merely excessive worries about real-life problems (like getting Covid-19 during the pandemic) or strong desires to have things arranged in a particular way; rather, they are irrational, intrusive, and persistent thoughts or urges.

In response to obsessions, people with OCD feel driven to perform compulsions—repetitive behaviors or mental acts applied rigidly and according to “rules” only they can discern. Although these compulsive rituals are meant to reduce obsession-related distress or prevent something bad from happening, they are typically excessive and not realistically related to the anxiety/fears that need to be resolved. Instead of bringing lasting pleasure, they may bring some temporary relief; but then the obsessive thoughts, urges or distress return and lead to further ritualistic responses and an ongoing cycle of worsening obsessive and compulsive behaviors.

Symptoms of OCD

OCD symptoms take many forms and may change over time. They affect each child differently, vary widely in severity, and typically worsen when a child is traumatized or under stress.

Following are common subtypes of OCD and the behaviors associated with them.

1. Obsessive fear of contamination: In this stereotypical form of OCD, kids worry about becoming infected by germs, getting sick, or making others sick (If I touch a doorknob and get germs, I’ll die).

Compulsive cleaning: To neutralize their fears or the likelihood of something bad happening, they may wash their hands excessively until their skin becomes raw; wash and re-wash food to avoid bacteria; clean doorknobs every time they open or close a door; constantly sanitize things around the house; or avoid places where they think they’ll pick up germs.

2. Obsessive fear of harm: Kids with feelings of heightened responsibility often worry that they will hurt themselves or others because of something they do or don’t do properly. For example, leaving the stove on will cause their house to burn down; failing to lock the doors will encourage a break-in; forgetting to wash food will cause a loved-one to become ill; or just thinking something terrible will cause the dreaded event to happen (If I have a bad thought … my Mom will get cancer; I’ll fail a test; God will punish me).

Compulsive checking: To reduce their anxiety or fears and to prevent imagined disasters, kids frequently use checking rituals that focus on safety and perfectionism, such as making sure the stove is off and the doors are locked so often during the night that their sleep is disrupted; or constantly checking in with family or friends to make sure they’re safe.

3. Obsessive need for symmetry: These are the kids obsessed with orderliness, exactness and an overall need for things to look, be, and feel “just right.” They may become overly anxious when an uneven number of pillows adorn the couch or the shoes on the floor don’t line up perfectly straight.

Compulsive arranging, organizing, counting, or evening up: They arrange/re-arrange clothes by color; avoid rooms where wall/floor tiles have particular shapes; or organize toys/items in certain ways (e.g. by precise size; facing the same direction; evenly spaced) and become overly frustrated if anything is moved out of place.

4. Obsessive need to accomplish tasks in a particular way: Similar to the need for symmetry (above), these kids must stick with something until it is “just right” (e.g., repeat words/sentences until they sound perfect; dress/undress in a certain sequence; count, tap or touch things a specific number of times).

Compulsive reworking until perfection is achieved. These kids may also start projects over and over again until they’re completed flawlessly (e.g., re-word emails or re-write sentences until they sound just right; re-form handwritten letters until they’re perfectly formed). These are also the kids who can’t start assignments until their environment is precisely the way they need it, with their room impeccably clean and the paper, pen, books, and computer all set up “just so.”

5. Pure Obsessions (Pure-O) without visible compulsions. Sometimes kids riddled by obsessive thoughts don’t have typical OCD behaviors but engage in unseen irrational or superstitious mental rituals or “magical thinking” to relieve distress or avoid feared outcomes (e.g., silently recite particular words, phrases or prayers; count in their heads to a certain rhythm/pattern).

Regardless of the subtype, OCD symptoms can be so intrusive and time-consuming that they wreak mental havoc, disrupt daily life, and become disabling to kids involved in activities at home, school, or in the community.

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This article is based on an ADDitude webinar, The OCD-ADHD Link: What You Should Know When You Have Both, by Roberto Olivardia, Ph.D. Olivardia is a clinical psychologist and clinical instructor of psychology at Harvard Medical School with a private psychotherapy practice in Lexington, MA. Eve Kessler, Esq., a former criminal appellate attorney, is Executive Director of SPED*NET Wilton (CT) and a Contributing Editor of Smart Kids.