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 hand-washing, counting, ordering, and checking. People do these things according to the 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. Due to your child’s compulsive habits, you may regularly run out of toilet paper, tissues, or paper towels.
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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 seven times before leaving home
- Looking for germs: your child is terrified 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 its 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
Compulsive Behavior Patterns vs. Repetitive Behaviors
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. They simply cannot participate in life in the same way as before these symptoms emerged.
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.
“According to the diagnostic manual 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 so much 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). 
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. You should contact a mental health professional or a child psychiatrist if they are significant.
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.
Rigidity often feels like stubbornness. It can be tricky for parents and clinicians to tease an actual compulsion symptom apart from a rigidity symptom. You may feel like your child is the honey badger, extremely determined to get their 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 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 specific rules for how things have to go, and they get stuck on everyone adhering to these rules. Like rigid behavior, as noted above, children with these tendencies get upset when plans don’t go as expected. The difference with insistence on sameness is that this 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 behaviors feel like habits. Another reason a child may do something repetitively is that they enjoy 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 they look 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 clinically called ‘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 the 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 result 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 alleviate 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 with 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
If your child has compulsive behavior that impacts day-to-day functioning, there is good news. These conditions and compulsive rituals can be treated. There are long-standing effective treatments for OCD. Consider a combination of support at home, psychotherapy, and medication to treat these symptoms.
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; your anxiety can worsen things. Both parent and child may need help here. To help you as a parent of a child with compulsive behavior, listed below are some strategies for one particular example of a compulsive behavior and what you can do about it.
How to help your child with a specific compulsion: hand-washing
A common compulsion is hand-washing. That is, some kids get obsessed with washing their hands to the point that their hands are cracked and bleeding. In this case, you can try a few strategies at home listed below. Keep in mind, though, that most parents will need help to implement these. Information about professional treatment is provided later in this article.
Validate your child’s concerns about germs.
Your child’s hand-washing behavior may be due to a high level of anxiety about germs. As a parent, you may be feeling frustrated and want to tell your kid to stop worrying. It will help your child more if you can validate their feelings. Validating your child’s experience does not mean you agree with the fear. It is letting your child know you heard them.
You can let your child know that it is normal to worry about germs and other seemingly scary things we encounter every day in life. However, it is also possible to pay less attention to those ‘threats’ by focusing on other aspects of our environment.
To validate your child’s experience, try this. Use the 3 R’s.
Resonate: First, simply resonate with your child’s fears. Say something like, “I understand that it can feel scary to be around germs.”
Relate: Next, relate your child’s experience to that of other people. Say, “It is normal to be afraid of certain things, like germs. Most people feel afraid at times.”
Redirect: Finally, redirect your child’s attention to something safe. Say, “Did you notice the cozy fireplace and the furry dog trying to get your attention?” Or you might try, “Remember, you are safe here in our home. Everyone here is healthy and well right now.”
In this way, you are not dismissing your child’s fears as irrational. You are teaching your child that it is normal to have fears but that you have the power to not listen to them.
Teach your child to recognize their anxiety about hand-washing.
Generally, compulsive habits are about anxiety. The child feels the anxiety and does the compulsion to push the anxiety away. A cycle begins where the child feels the anxiety, does the compulsion, and the anxiety goes away for a minute. Then, when the anxiety comes back again, the child feels ‘compelled’ to do the behavior again. Anxiety is somatic, which means it is felt in the body. One way to help your child is to share how common anxiety is and what it feels like when it comes up in your body.
You can say, “Oh, here’s that worry bug again. I feel that tingling in my lips and butterflies in my tummy. I can handle it. It is okay for me to let anxiety come in and pass through. Just like a cloud, I let my worries come and go.”
Gently teach your child that pushing away one’s fears with compulsive behavior does not really help. Instead, your child can learn to recognize the anxiety and use a strategy to calm down in the face of it.
Reading a story such as Please Explain Anxiety to Me! by Laurie Zelinger can help your child understand the biology of anxiety. If your child is a little older, a great resource is Outsmarting Worry (An Older Kid’s Guide to Managing Anxiety) by Dawn Huebner.
Teach your child that intrusive thoughts about hand-washing are like brain spam.
When your child has a compulsive need such as hand-washing, it is like a spam message. Spam, such as the messages we get in our inboxes, is annoying and ‘intrusive.’ If we go onto social media and ‘like’ something, we often get more of those same spam messages.
Compulsions are the same. When your child gives into the fear and anxiety to wash their hands, the mind will create more anxiety-provoking thoughts. The way to overcome this is to pay attention to something else. Instead of focusing on the thought, your child can redirect their attention to the present moment experience. Your child can begin to notice that they are safe and secure right now.
Normalize the experience of ‘spooky thoughts’ about hand-washing
Intrusive thoughts are not unusual. It can be helpful for your child to know that. Let your child know that it is normal for thoughts to just pop in our heads. Teach your child to stand up to those thoughts. Your child is not creating the thoughts. The thoughts have no power except the power we give them.
Just like a TV station with a lot of bad news, we all have to face distressing thoughts. When it comes to our thoughts, we can’t just turn them off. Instead of tuning into the thoughts, though, we can change the channel. Your child can learn to focus instead on other sensations in the environment. It is possible to begin to notice a gentle breeze, a dog’s soft fur, or the sun’s warm rays. In this way, the intrusive thoughts are not in charge.
Teach your child anxiety-reducing strategies about germs
You want to teach your child how to relax their body in a healthy way. You can teach your child how to take deep breaths, relax their muscles, and change their thoughts. Are you looking for specific strategies that will help, a great resource for you is Cadey’s child anxiety course.
Create a goal about hand-washing
As your child begins to work on their compulsive behavior, it can be great to set a goal. We want your child to reduce the number of times they wash their hands. When your child becomes worried and feels the impulse to wash their hands encourage them to use an anxiety-reducing strategy. Start with something simple like, I will resist the urge to hand wash 3 times per day.
One way to immediately reinforce this behavior is to reward the use of a coping strategy instead. For example, you could have a bin of small toys, and at the end of the day, if they are successful, they earn a toy. This way, the reward is immediate. If your child can delay gratification, they could earn a sticker as progress towards a larger prize.
Seek out therapy
All of the above strategies can be great so long as your child’s obsession with hand-washing is not prolonged or severe. If your child is compulsively hand-washing to the point that life feels unmanageable, it is time to get help. The main sign to be on the lookout for is your child’s willingness to participate in activities they enjoy. Is your child avoiding school events where there may be germs? Is your child dropping out of sports that used to be enjoyable? If so, it is time to seek out therapy.
What to do with professional help for compulsions in childhood
When your child’s compulsive behaviors are getting in the way of their participation in activities they enjoy, it is time to seek help. You would notice that your child is skipping out on school events, sports, or other social activities. You might also notice your child is extremely anxious all the time. In that case, you will want to work with a therapist who treats Obsessive-Compulsive Disorder.
Gradual exposure with response prevention
The best therapy for compulsions is something called ‘Gradual Exposure with Response Prevention.’ As the name implies, this therapy includes gradually introducing your child to the feared stimulus while disallowing the compulsive response. For example, if your child is so afraid of germs that they just ‘have to’ wash their hands, the therapist would gradually introduce some environments with germs. Your child would be taught to tolerate that stimulus by using a coping strategy. After a while, the child comes to see that it can be okay to be around germs for a while without washing their hands. Generally, nothing bad happens. The sequence is reinforced because the feared object (getting sick) does not come to be. Rather, the germs are there and the child is still calm and safe.
With the support of a therapist, your child begins to face the ‘threat’ of germs and see that nothing happens, a new kind of tolerance is built. Your child is now capable of being somewhat calm with the germs around. In this way, your child is systematically learning to loosen up some control and still feel safe and comfortable.
This therapy is part of something called Cognitive Behavioral Therapy (CBT). This modality has considerable research to support its effectiveness. CBT can be paired with exposure response prevention treatments.
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, and parents or family members may be involved to practice these important skills learned in therapy.
What to do with medication for compulsions in childhood
A further option for families is to consult a child psychiatrist regarding medication for anxiety. For some children, even with treatment, the anxiety is so strong that medication is required to begin to stabilize. Often, these compulsions are temporary and children will not need to be on medication for them very long. In the case that your child’s anxiety is debilitating, medications can be a facilitator of stability, growth, and progress.
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
 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
Cook, Julia (2012). Wilma jean and the worry machine.
Culbert, Timothy & Kajander, Rebecca (2007). Be the boss of your stress (Be the boss of your body®).
Huebner, Dawn (2007). What to do when your brain gets stuck: A kid’s guide to overcoming OCD.
Huebner, Dawn (2017). Outsmarting Worry (An Older Kid’s Guide to Managing Anxiety).
Peters, Daniel B. (2013). From worrier to warrior: A guide to conquering your fears.
Zelinger, Laurie & Zelinger, Jordan (2014). Please explain anxiety to me.