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FeelingCompulsions

Is Your Child Insisting It Has To Be Just So?

Marcy Willard
Marcy Willard
Ph.D., NCSP
Last modified 19 May 2022
Published 11 May 2022

What are Compulsions in Childhood?

Compulsions in childhood are repetitive behaviors that a person does to relieve excessive anxiety.

Compulsive behaviors are unique in that the individual feels that they simply ‘have to’ do the ritual or routine to feel better. Compulsive behaviors are performed to reduce anxiety, but they are not realistic solutions to cope with unwanted thoughts or urges. Compulsions include handwashing, counting, ordering, and checking. A person does these things according to strict rules they have set for themselves. 

It is one thing to be a tad too organized. It is another when having things out of order causes extreme distress. Your child may obsess about cleanliness or germs. They may wash their hands or use sanitizer repetitively. They may have repetitive rituals that do not seem to serve a purpose. Your child may constantly be ‘checking’ for germs or potential dangers. You may be constantly running out of toilet paper, tissues, or paper towels due to your child’s compulsive habits.

“Your child may say, “But I have to,” as they insist on cleaning or organizing something over and over again. They may be scared to go certain places or eat certain things based on these worries and concerns.”

Your child may have to complete a ritual or routine before leaving the house. For example, your child may check that every appliance is unplugged and every light is turned off before leaving home. You may often be late to places because of this ritual.

You may also notice that your child’s hands are red and inflamed from hand washing, or that your child’s anxiety is causing them to miss out on important events or activities. Some children’s anxiety is so intense that they are ‘frozen’ or somewhat paralyzed and simply cannot participate in life in the same way as before these symptoms emerged.

Symptoms of Compulsions in Children

  • Washing hands too much: your child’s hands may be chapped, cracked, or bleeding
  • Anxious: your child is experiencing extreme anxiety if things are not ‘just so’
  • Checking behavior: your child is often checking and counting things, like whether their toys are lined up properly, their drawer is closed the right way, or the light is turned off in their room
  • Ritualistic behavior: your child is doing repetitive rituals that don’t serve a function like walking in squares, skipping over the cracks in the sidewalk, counting their toys, or needing to flip the light switch 7 times before leaving home
  • Looking for germs: your child is extremely afraid of germs and this behavior is interfering with day-to-day life. Of course, these symptoms are exaggerated for many kids during the pandemic and aftermath. It is important to reassure your child that you are safe and healthy and it is safe to go out, given reasonable precautions
  • Clinging to worries: your child cannot let it go when things do not go perfectly or just as expected 
  • Compulsive bathing: your child takes extremely long showers or takes excessively long to get ready in the morning
  • Uneasy demeanor: your child seems unsettled and upset most of the time 

According to the diagnostic manual that psychologists use, individuals set rules for themselves and are driven to perform a compulsion in response to an obsession. An obsession is a persistent thought or urge that is recurring, unwanted, and intrusive. 

Not all repetitive behaviors are compulsions. Some repetitive behaviors are performed because a child has a specific and intense interest. Rolling a car over and over because you love cars and are obsessed with cars is not a compulsion. 

Repetitive behaviors related to a special interest tend to mean that a child performs the act because they like or love it, not because it relieves anxiety. This kind of behavior is often related to the Autism Spectrum, while compulsions in response to unwanted obsessions are rare in young children and are symptoms of Obsessive-Compulsive Disorder (OCD). Obsessive-Compulsive Disorder most often begins in adulthood. Only 25% of cases start in childhood, with 25% of males showing signs before age 10 (DSM-5, 2013). [1]

Parents often visit psychologists to ask, “Does my child have OCD?” Very often, the answer is, “No, we’re seeing a repetitive behavior that could be a part of autism” OR “No, this behavior is related to anxiety, not OCD.” When a parent visits a doctor with this concern for a 4- or 5-year-old, OCD is generally not the answer. 

As your child gets older, take note of any compulsions you notice. If they are significant, you should contact a mental health professional or a child psychiatrist. 

Causes of Compulsive Behaviors

It is important to understand that most seemingly compulsive behaviors are not symptoms of Obsessive-Compulsive Disorder (OCD). OCD is fairly rare in childhood. Before jumping to that conclusion, consider some of these potential causes of compulsions first.

Rigid behavior 

Rigidity often feels like stubbornness. It can be tricky for parents and clinicians to tease a true compulsion symptom apart from a rigidity symptom.  You may feel like your child is the honey badger, extremely determined to get their own way. Kids who are rigid often need to have things a certain way for the comfort of routine. Children with rigid behaviors will often be distressed if things do not go exactly as expected. They will be upset if there is a substitute teacher, an assembly, or an assessment day at school.

Insistence on sameness

Insistence on sameness feels like worry. Another reason why a child may have some compulsive behaviors could be a personality characteristic. Some kids get very upset when they do not know what to expect or when things change. It is like they have certain rules for how things have to go, and they get stuck on everyone adhering to these rules. Just like rigid behavior, noted above, children with these tendencies get upset when plans don’t go as expected. The difference with insistence on sameness is that it tends to be a long-standing aspect of the child’s personality, temperament, and demeanor. In fact, there is now evidence of a genetic link in terms of this tendency to insist on sameness. Does a parent or grandparent really like things to stay the same? Your child may have inherited that trait as well. 

Repetitive behavior

Repetitive behaviors feel like habits. Another reason why a child may do something repetitively is that they are enjoying that behavior. For example, a child may simply love the feeling of rocking or spinning. They may like to line up their favorite toys because it looks so nice and organized. Your child’s behavior is related more to a specific interest and does not necessarily serve the purpose of relieving anxiety. In that case, this behavior is generally referred to as a ‘repetitive behavior’ and is not a compulsion. 

Obsessive-Compulsive Disorder (OCD)

Compulsions feel like obsessive rituals. Nonfunctional routines or rituals used to relieve anxiety are referred to clinically as ‘compulsions.’ The underlying problem could be an obsessive-compulsive disorder (OCD)  or an obsessive-compulsive personality type. OCD is characterized by obsessions over something, such as germs, and corresponding compulsions are used to relieve anxiety. 

The critical thing to think about with compulsions is the level of difficulty the habit or ritual is having on your child. If your child’s hands are raw and inflamed from constantly washing them, or if you are always 20 minutes late for activities because your son had to turn off every light in the house 5x before leaving, the compulsions could be worthy of treatment. 

Extreme anxiety and unrelenting, obsessive thinking are often the results if the child doesn’t perform the compulsive behavior. For example, a child might feel highly anxious if they cannot wash their hands five times before leaving the house. This compulsive routine may be alleviating the obsessive worry that their hands are covered in germs. 

If compulsions are a significant problem for your child, these experiences could be miserable. The anxiety may become overwhelming. They want these feelings, rituals, and acts to go away. If you see this in your child, do seek help. Consider if you have a family history of OCD in your extended family. 

Compulsions are treated with Cognitive Behavioral Therapy and sometimes with prescription medications for anxiety. These symptoms are pretty amenable to interventions and therapy.

Causes of Obsessive-Compulsive Disorder in Childhood

  • Genetics: Obsessive-Compulsive Disorder (OCD)  is much more common among first-degree relatives, especially if that relative had OCD as a child. If you have OCD in the family and see these symptoms in your child, find the right therapist and include your pediatrician in the conversation. OCD is a treatable challenge but needs immediate attention and support
  • Abuse in childhood: Obsessive-Compulsive Disorder is more common in children who have experienced abuse or stressful and traumatic events in childhood. If you are caring for a child who has had these experiences, they need to have the right therapist in their life. Mental disorders are far more common for children who have experienced abuse or trauma, and support is available.
  • Significant anxiety and negative emotionality: Obsessive-Compulsive disorder can emerge in a child who has certain personality traits and emotional symptoms. A very anxious and sad child would benefit from therapy and support early to not develop OCD as they get later into childhood.
  • PANDAS: Obsessive-Compulsive Disorder is sometimes related to a condition called PANDAS. You may also consider whether your child has had repeated Strep Throat infections. Anxieties and worries associated with PANDAS are rare. But, discuss with your pediatrician if your child has these symptoms and has had repeated Strep infections. 

What to Do About Compulsions in Childhood

Here is what to do if you are concerned about your child’s compulsions.

What to do at home for compulsions in childhood

At home, support your child with warmth and patience. Do not punish compulsive behaviors. The best thing you can do at home is to be open and listen to your child. Bring the thoughts and compulsive behaviors to the forefront, giving them attention and support, not shame and hiding. Your child needs to feel supported, and your anxiety can make things worse. Both parent and child may need help here.

What to do with professional help for compulsions in childhood

If your child has compulsive behavior that impacts day-to-day functioning, seek professional help. Consider a combination of psychotherapy and medication to treat these symptoms.

Work with a professional to gradually expose your child to feared stimuli like germs. Cognitive Behavioral Therapy (CBT) is a modality with considerable research to support its effectiveness. CBT can be paired with exposure response prevention treatments. 

By gently and gradually introducing the child to the feared situation, and teaching them to calm themselves in the face of it, anxiety can begin to dissipate. For example, a child with OCD may slowly work towards touching something with germs and not washing their hands right away. The child is slowly and gradually presented with the situation but is unable to complete the compulsive ritual. With adequate support, these rituals will lose some of their hold on your child’s thinking patterns and habits.

Cognitive Behavior Therapy can help kids understand their own obsessions and anxiety, recognize worry and fears, and develop healthy and appropriate coping strategies. OCD treatment is generally individual therapy, but parents or family members may be involved to practice exposure with response prevention.

Further Resources on Compulsions

  • Psychotherapist or play therapist: to treat emotional symptoms and anxiety. Cognitive Behavioral Therapy is the best practice treatment for OCD. This approach teaches your child to remain calm while not carrying out their compulsive routine.
  • Medical Doctor (pediatrician or psychiatrist): to consult and be involved in this treatment. Regular check-ins will be essential if you decide to use medication to help your child. Medicine and therapy may be the best approach.
  • Psychologist or neuropsychologist: to consider a full assessment to look at symptoms in a mental health context

Similar Conditions to Compulsions in Childhood

  • Anxiety: excessive worry that has an impact on day-to-day functioning can result in compulsions
  • Depression: depressed mood, or, in children, pervasive irritability; decreased interest in activities that used to be enjoyable may result in compulsions
  • Attachment disorder: emotional symptoms like anxiety and depression as well as rigidity and extreme behaviors that stem from challenges in attachment to primary caregivers (death of a parent, change of caregivers, abuse in the home) can lead to compulsive behavior
  • Autism spectrum disorder: deficits in social communication and restricted interests or behaviors that may lead to a preference for routine, repetitive, and compulsive behavior
  • PTSD: reactions to a traumatic situation with fear and need for things that are predictable and comfortable can lead to compulsive behavior

Resources About Compulsions in Childhood

References about compulsions in childhood

[1] American Psychiatric Association. (2013). Obsessive-Compulsive Disorder. In. Diagnostic and Statistical Manual of Mental Disorders (5th ed.)p. 235-240.

Resources about compulsions in childhood

Huebner, Dawn. (2007). What to do when your brain gets stuck: A kid’s guide to overcoming OCD. 

Huebner, Dawn (2005). What to do when you worry too much: A kid’s guide to overcoming anxiety (What to do guides for kids).

Zelinger, Laurie & Zelinger, Jordan (2014). Please explain anxiety to me. 

Cook, Julia (2012). Wilma jean and the worry machine. 

Peters, Daniel B. (2013). From worrier to warrior: A guide to conquering your fears.

Culbert, Timothy &  Kajander, Rebecca (2007). Be the boss of your stress (Be the boss of your body®).

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