Obsessive compulsive disorder presents slightly differently between children and adults.  If we use the metaphor of a cold – it starts off sounding and feeling one way but develops over time, seemingly moving in the body and gathering strength.  However, from the first day you start to cough you will recognise it as a cold.  Like a cold, OCD has many easy to recognise traits.

One of the most common ways to assess a child over 6 years old for OCD symptoms it to use a questionnaire called the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS).   It has ten items and is completed by an experienced therapist.  Like all checklists it balances the need to keep the test short and simple with maximising the accuracy of the diagnosis.  To get down to just ten questions some diagnostic criteria are thrown out.  The rejected questions may capture subtle features that while important or uncommon don’t significantly improve the accuracy of the test for the majority of the people being tested.

Adam Lewin and co-researchers have published a paper talking about some of the clinical features of OCD in children that don’t get as much attention as others.  The six factors that the authors felt need additional attention include:

  • insight
  • avoidance
  • indecisiveness
  • overvalued responsibility
  • pervasive slowness
  • pathological doubting


So, in this post we will briefly explore these six factors to aid in the diagnosis of OCD in children.

Insight into obsessions and compulsions

Children can be egocentric.  The world revolves around them and so an awareness of how they think and behave relative to others may be reduced compared to adults.  If a child understands that that compulsions can be a problem for other people then this shows some insight.  The child may also show insight in that these behaviours are not normal compared to other people.  Poor insight is associated with clinical severity and a greater likelihood they have additional common mental health issues such anxiety and depression.



A child with a contamination concerns is unlikely to want to touch thing that are ‘dirty or germy’.  They may avoid places that they believe are unsafe or use gloves and clothes when approaching a contaminated object.  If a child displays high levels of avoidance such as not attending school and avoiding peers then this is associated with poor life functioning.


Degree of indecisiveness

Many people can be indecisive but if it with small, routine and mundane matters then this is associated with increased OCD behaviour.  For adults it is associated with hoarding.


Overvalued Sense of Responsibility

An overvalued sense of responsibility is fairly central to OCD.  It stems from a broad belief that an individual is responsible and can influence events in the world that others may perceive as uncontrollable.  People with OCD often believe that thinking something will directly impact the external environment.  For a child it may mean a bad thought (e.g. swearing at a brother) may be the causal action that results in future harm to a parent. This is called thought-action fusion (TAF).  The OCD rituals serve to neutralise the future harm.


Pervasive Slowness/Disturbance of Inertia

If a child is mentally or physically engaged in obsessions or compulsions they are not fully focused on daily tasks or play.  A child may seem ‘stuck’ if they need to switch from a distracting obsession to a parental defined goal such as getting dressed for school.


Pathological Doubting

Did I hand in that school assignment in class?  I don’t think I returned all my library books?

These thoughts may result in excessive reassurance seeking, questioning, repeating or checking.  Doubt is seen as a key element in the development of OCD and a very distinctive feature in adult OCD.



The standard CY-BOCS examines the time occupied by, interference and distress from, resistance to, and control over obsessions and compulsions.  The authors found that the six factors of insight, avoidance, indecisiveness, overvalued responsibility, pervasive slowness and pathological doubting provided additional guidance in treatment planning over the CY-BOCS.



Lewin, A. B., Caporino, N., Murphy, T. K., Geffken, G. R., & Storch, E. A. (2010). Understudied clinical dimensions in pediatric obsessive compulsive disorder. Child Psychiatry and Human Development, 41(6), 675-691.


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