Assessing OCD in children

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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Magical thinking extends to GAD

We are not totally rational beings.  That is why Spock from Star Trek was so interesting and unique.  Part of our irrationality is the ability to believe in causality that is not directed solely by the laws of science.  That is other forces such as fate and karma can influence our lives.  The American Psychological Association argue that commonly accepted beliefs that often centre around a higher power or horoscopes are acceptable beliefs.  Non-scientific beliefs that are not culturally accepted are described as a result of magical thinking.  So beliefs fall roughly into three zones.  One, rational; two, non-scientific but widely accepted and three, individual magical thoughts.  It is the latter that is a feature of obsessive compulsive disorder (OCD).

An OCD thought that involves magical thinking typically involves an action or a thought that is used to protect themselves or loved ones from harm.  For example if I would turn the door handle right and then three times left, then my family will be protected.  The magic is in believing that these actions can directly influence the safety of the family.  Such thought are usually unique to the individual.

People without OCD indulge in magical thinking.  Do you own some lucky charm – a talisman that protects or grants you a little more good fortune than than random luck? A charm that promises good fortune requires that the possesor to indulge in magical thinking.  Such simple examples show us that magical thinking is practiced by many in everyday life.  It is very common for people to believe that there are forces beyond rational science that can influence our lives.  The magical thinking found in OCD is therefore not such a strange thing.  It is simply an exaggeration of commonly accepted magical thoughts.

The idea of forces beyond rational science is abundant so what makes OCD thoughts extra magical?  OCD thoughts frequently involve a unique belief with very specific requirements. To a regular observer the OCD behaviour may look rational.  People who have OCD thoughts about germs may shroud their actions in the science of cleanliness but beneath the surface my lie unsupportable beliefs around the real risk of contamination and the consequences of coming into contact with people and surfaces.  An example of magical thinking is where a ‘bad’ deed (sin) can be passed on like a germ from person to person.  Contamination of germs and ‘bad karma’ can merge in a magical thought.  In a world where superstition has a hidden foothold then magical thinking is not easy to dismiss.

In fact the oddness in OCD magical thinking is more that almost no-one else shares that same magical belief.  There are rather a lot of people who would resist removing the protective dangly thing hanging from the rear view mirror.  These protective dangly things represent shared magical thinking.  As such it is perfectly OK to have these beliefs and be free from a diagnosis of OCD.  If I say that my rear view mirror dangly thing has been replaced with an oversized teddy bear that I keep in the rear passenger seat then all of a sudden I appear a little odd.  The teddy that I keep in my back seat proves that I am just on the leading edge of superstitious protection.  Of course it only works if you have the giant teddy wearing a seatbelt (otherwise you are just asking for trouble).

Magical thinking has one other feature that makes it appear strange.  Magical thoughts do not work. This is perhaps a very overlooked feature of magical thoughts.  But there failure to work as predicted is no barrier to belief.  Insurance companies do not believe that having a lucky charm/teddy in the car will protect you.  I do not get a reduction on my insurance if I keep my giant teddy in the back seat.  Actions such as counting and saying safety phrases to neutralise bad things has no effect on the world.

We indulge in magical thinking because of the ‘just in case‘ it might work principle.  While Richard Dawkins would dismiss the idea that a deity can offer you eternal life after death there is a very compelling argument to convert at least at the end of your life.  It might just work and there is no significant downside.  That is unless your deity has a special place in hell for agnostic opportunists.  Sadly, Mr Dawkins is going straight to the 9th level of Dante’s hell and all it would take would be a simple ‘sorry’ to save him from eternal damnation.  What does he have to lose?

So magical thinking is ubiquitous and hard to eliminate.  Welsh researchers West and Willner measured the level of magical thinking in people with generalised anxiety (GAD), OCD and people without a OCD diagnosis.  What they discovered is that people with OCD had high levels of magical thinking compared to normal individuals.  Nothing special there.  Interestingly they found that people with GAD had similar level of magical thinking as people with OCD.  The researchers suggested that GAD and OCD have some close connection to each other.  They propose that the constant worrying found in GAD may involve an element of magical thinking where constantly exploring of the fear provides the perception that they are able to limit the effects of the fear.



Behavioural and Cognitive Psychotherapy, 2011, 39, 399–411
First published online 21 February 2011 doi:10.1017/S1352465810000883

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Disclaimer: This content is not intended to provide medical or mental health advice.  It is intended to stimulate an increased understanding of OCD.  The content may not be accurate or express the views of the journal article authors.