Obsessive-compulsive disorder (OCD) in childhood is more common than previously thought. Recent studies estimate its prevalence in children and adolescents to be between 1% and 3% of the general population. The age of onset appears to follow a bimodal distribution, with a first peak during childhood (around age 10) and another in adulthood . It is estimated that approximately 25% of all OCD cases begin before the age of 14 .

In childhood, the disorder is more common in boys than in girls, but this difference evens out during adolescence and adulthood. Furthermore, a significant genetic component has been observed, so the risk of developing OCD is ten to twelve times higher if a first-degree relative developed the disorder at a young age.

Detecting obsessive-compulsive symptoms in childhood isn't always easy. Many behaviors that might seem worrisome are actually part of normal development. For example, young children often exhibit ritualized behaviors , such as always following the same bedtime routine, wanting to hear the same story every night, or insisting on performing certain activities in a specific way. They may also display superstitious or magical beliefs , such as thinking that wearing a "lucky" shirt will help them on a test.

Children have less ability to identify their obsessive thoughts; they often lack the maturity to recognize that their compulsive actions are disproportionate or unreasonable.

These behaviors usually decrease naturally from the age of 7, so the child's age is a key element in assessing whether the rituals are developmentally normal or if they are starting to become problematic.

Furthermore, unlike adults, children have less ability to identify their obsessive thoughts . They often lack the maturity to recognize that their compulsive actions are disproportionate or unreasonable and lack the vocabulary and understanding needed to express what they are experiencing. Children may not be able to distinguish between reality and fantasy, making it difficult for them to question the validity of the connection between their thoughts and behaviors . Many children may sincerely believe that their rituals are necessary. For example, a child might think that if they don't repeat a phrase several times in their mind, something bad could happen to their parents.

In addition, some children may feel ashamed of their thoughts or fear the reaction of others, so they don't always talk openly about what's happening to them. For this reason, the family plays a key role in the early detection of possible symptoms.

What warning signs of OCD can families detect?

In many cases, the first signs are subtle changes in behavior. Some signs that may alert families are:

• Constantly involve the family: constantly ask for reassurance: "Are you sure I won't get sick?", "Are you sure I haven't done anything wrong?", "Do you forgive me for what I thought?".
• Extreme slowness in everyday tasks: simple activities can become very long because the child feels they must do them "the right way." For example, taking a long time to get dressed or do homework because they need to repeat actions several times.
• Irritability: Outbursts of anger if a ritual is interrupted or if something is not exactly as they believe it should be.

In other cases, the symptoms are more obvious . Some behaviors that may appear are:

• Wash your hands repeatedly , lock and relock doors, or touch objects in a specific order.
• Extreme or exaggerated fear of contamination , of family members being hurt or injured, or of harming themselves.
• Use of magical thinking , such as: "If I touch everything in the room, Mom won't die in a car accident."
• Repeated search for guarantees about the future.
• Intolerance to certain words or sounds.
• Repeated confession of "bad thoughts," such as cruel thoughts (thinking that a family friend is ugly), sexual thoughts (imagining a classmate naked), or violent thoughts (thinking about killing someone).

To identify potential symptoms, it's also important to keep in mind that OCD can begin with one obsession or compulsion that can last for a very variable amount of time and may later change to one or more different ones. For a diagnosis of OCD, the symptoms must interfere with the daily lives of children and adolescents, potentially affecting their self-esteem, mood, family life, and academic performance.

We should be alert if he repeatedly confesses cruel, sexual, or violent thoughts towards others, if he has an extreme fear of contamination, or if he has an intolerance to certain words or sounds.

What are the most common obsessions and compulsions in childhood and adolescence?

In children and adolescents with OCD, certain patterns of obsessions and compulsions tend to appear more frequently.

Obsessions

• Fear of contamination: excessive fear of germs, dirt, or sticky substances.
• Fear of harm: recurring thoughts that something terrible will happen to them or their parents (accidents, illnesses). Fear of being able to harm others or intentionally harming themselves, fear that others will be harmed because of what they have done or failed to do.
• Need for symmetry and order: feeling that things must be perfect or in an exact place to prevent something bad from happening.
• Taboo thoughts: aggressive or inappropriate ideas that feel "bad" and that generate a lot of guilt.
• Magical or superstitious thoughts: wearing underwear of a certain color or performing everyday activities a certain number of times.

Compulsions

• Washing and cleaning: washing hands excessively, taking very long showers, or avoiding touching certain objects (doorknobs, shoes).
• Verification: check many times if the backpack is closed, if the light is off, or if the door is locked.
• Repetition: reading a sentence over and over, going in and out of a room, or touching an object until it feels "good".
• Ordering and placing: need for symmetry or alignment of objects in a specific way.
• Mental rituals: praying silently, counting numbers, or repeating words to "cancel out" a bad thought or to prevent something bad from happening.

What can the family do?

Once a diagnosis has been made, family involvement is crucial. Parents are usually the ones who spend the most time with their children and who can help them apply the strategies learned in therapy to their daily lives.

A key aspect that needs to be addressed is family adaptation . This term refers to situations in which family members, with the intention of helping, participate in their children's rituals or modify their routines to alleviate their anxiety. There are many forms of family adaptation: from constantly answering questions related to their obsessive thoughts, to canceling vacations, going out to restaurants, or even changing the way they speak to avoid situations that trigger their children's anxiety. They may avoid specific names, numbers, colors, and sounds that cause them distress.

By adapting to their child's obsessive-compulsive symptoms, parents may think they are offering comfort, and it's true that they may feel better in the moment, but this relief is fleeting and, in fact, can reinforce their anxiety in the long run . Anxiety is maintained through avoidance, so family members who adapt to their children are actually making the symptoms more entrenched. Therefore, trying to shield them from the things that trigger their fears can be counterproductive. By acting naturally, they are inadvertently adapting to the disorder and allowing it to take over their life.

When families adapt to or participate in their children's rituals to protect them, they are actually reinforcing their long-term anxiety and making it easier for the symptoms to become more entrenched.

The standard treatment for pediatric OCD is a form of cognitive behavioral therapy (CBT) called exposure and response prevention ( ERP). This therapy involves gradually and systematically exposing the child to their anxieties so they stop fearing and avoiding those objects or situations. "Response prevention" means that the child is not allowed to perform a ritual to manage their fears. Because parents are so involved in their children's OCD, research has shown that including them in treatment and assigning them as "co-therapists" improves its effectiveness.

Much of the work in CBT involves practice outside of sessions, which requires family involvement. Children are assigned tasks and asked to continue practicing coping with their fears in various settings. Because exposure and response prevention can be anxiety-inducing and require considerable follow-up, family involvement and support are essential.

The role of the family in OCD: accompanying, understanding and collaborating

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Key information about OCD in childhood

OCD can appear in childhood and, although it sometimes goes unnoticed, early detection is essential to prevent it from significantly interfering with the child's development.

Recognizing the warning signs , understanding how the disorder works, and seeking professional help are key steps. With appropriate treatment and family support, most children with OCD can learn to manage their symptoms and lead fulfilling and functional lives.

Families are not only part of the problem when they unknowingly adapt to their children's rituals; they can also become a fundamental part of the solution, accompanying them in the process of learning to face their fears .