Obsessive-Compulsive Disorder (OCD) and related disorders, including Body Dysmorphic Disorder (BDD), often begin in childhood or adolescence and can be associated with marked distress, impaired school functioning, family disruption, and increased risk of comorbidity and co-occurring symptoms. Late research has advanced researchers and clinicians understanding of risk factors, developmental trajectories, and long-term outcomes, while refining evidence-based assessment and treatment pathways. Alongside established evidence-based psychological interventions, evolving clinical approaches include improved stepped-care models and digitally delivered therapies designed to expand access, highlighting at the same time the need for adaptations for neurodivergent young people and for those facing systemic barriers to care.
Childhood-onset OCD and related disorders can be highly impairing but are treatable with evidence-based approaches.
Why childhood-onset OCD matters
OCD is characterised by intrusive thoughts, images, or urges (obsessions) and repetitive behaviours or mental acts (compulsions) performed with the aim to reduce distress or prevent feared outcomes. OCD can present with themes such as contamination, harm, symmetry, moral/religious fears, or “just-right” sensations, and may present with avoidance and reassurance seeking. Related disorders include BDD, hoarding disorder, trichotillomania (hair pulling disorder), and excoriation (skin picking disorder), which share phenomenological and neurocognitive features and can similarly disrupt development and functioning. Childhood-onset OCD is associated with significant impairment and adverse functional outcomes when untreated. School and education disruption, and reduced participation in peer and family life are common. Furthermore, burden on caregivers can be substantial. Current evidence links OCD to elevated risk for later adverse outcomes, including psychiatric comorbidity, reinforcing the importance of early recognition and effective intervention (Carmichael et al., 2021; Fernández de la Cruz et al., 2020).
Early identification and effective treatment of OCD may reduce long-term functional and mental health burdens.
Classification and assessment in clinical practice
Diagnostic classification of OCD and related disorders has evolved, with many systems now grouping these presentations together due to shared features and underlying mechanisms. In practice, classification supports systematic assessment of symptom dimensions, severity, insight, and associated impairment. For children and adolescents, assessment also requires careful developmental framing: young people may struggle to articulate obsessions, may present with irritability or behavioural avoidance, and may involve caregivers in rituals, prompting family accommodation. Evidence-based assessment typically combines a structured clinical interview with the child/young person and caregiver, standardised symptom and severity measures (e.g., CY-BOCS for OCD), assessment of comorbidity (especially anxiety, depression, tics, autism traits, and externalising difficulties), evaluation of family accommodation and functional impairment, and structured risk assessment (including suicidality, self-harm, and safeguarding concerns). Recent guidelines continue to emphasise that OCD is frequently missed or misdiagnosed (for example, as general anxiety, oppositionality, or perfectionism), contributing to treatment delays and avoidable increase in severity (NICE, 2022; AHRQ, 2024). These delays are clinically important because longer duration of untreated illness is associated with poorer outcomes since OCD can become increasingly entrenched via avoidance, family accommodation and reinforcement cycles.
Comprehensive, developmentally sensitive assessment is central to distinguishing OCD from normative worries and other anxiety presentations.
Risk factors and developmental pathways
OCD is a complex, multifactorial condition influenced by genetic vulnerability and developmental experience. Family and twin studies signal substantial heritability, and contemporary models suggest OCD risk as distributed across multiple genetic variants interacting with environmental exposures. Frequently discussed exposures in the literature include bullying, trauma, and chronic stress, which may amplify symptom onset or worsening through mechanisms such as threat sensitivity, heightened responsibility beliefs, and avoidance reinforcement. These factors are particularly relevant clinically because they are associated with comorbid anxiety, depression, and post-traumatic symptoms, which can complicate OCD treatment and require integrated planning.
Risk factors for childhood-onset OCD are multifactorial; genetically informed studies caution against simple causal conclusions for single exposures.
Consequences: health, psychosocial, and socioeconomic outcomes
Childhood-onset OCD can shape developmental opportunities at critical stages. Functional impairment can include school refusal or reduced attendance, missed learning due to rituals and avoidance, and peer difficulties driven by shame, secrecy, or misinterpretation of symptoms. Family functioning is commonly affected, especially when caregivers become involved in rituals or avoidance patterns (Family Accommodation). Recent research suggests that OCD is associated with increased psychiatric comorbidity and broader adverse outcomes across health and functioning. Population-based studies have reported higher risks of a range of psychiatric outcomes and indicators of reduced educational and occupational attainment in those diagnosed with OCD, underscoring the long-term relevance of effective early treatment pathways (Carmichael et al., 2021; Fernández de la Cruz et al., 2020).
OCD affects more than symptoms: it can disrupt education, relationships, family life, and long-term opportunities.
Evidence-based treatments: what works best
Cognitive Behavioural Therapy (CBT) with Exposure and Response Prevention (ERP) remains a first-line psychological treatment for paediatric OCD. ERP supports the young person to gradually face feared situations (exposure) while reducing or postponing rituals and safety behaviours (response prevention), with careful attention to developmental fit and collaborative engagement. Treatment commonly includes psychoeducation, hierarchy building, in-session and between-session exposures, relapse prevention, and caregiver work targeting accommodation. Current guidelines continue to recommend ERP-based CBT as a core intervention, with intensity matched to symptom severity and impairment (NICE, 2022; AHRQ, 2024). For moderate-to-severe OCD, combined treatment approaches are often considered, particularly when access to specialist CBT is limited or when functional impairment is high. Regarding pharmacological treatment Selective Serotonin Reuptake Inhibitors (SSRIs) have evidence for paediatric OCD, particularly for moderate-to-severe cases and when CBT is unavailable, insufficient, or not acceptable. Medication decisions should be individualised, taking account of comorbidity, risk, family preferences, and careful monitoring of adverse effects. Many services use a stepped-care model in which CBT is offered first, with SSRIs added when required, or combined upfront in more severe presentations (NICE, 2022; Shahidullah et al., 2023).
ERP-based CBT is a core first-line treatment; SSRIs are commonly used for moderate-to-severe presentations or when CBT is not available or sufficient.
Evolving clinical approaches: stepped care and digital interventions
Access to care remains a major barrier in paediatric OCD, with many areas reporting insufficient specialist CBT capacity. Therefore, stepped-care models have gained attention, aiming to provide the least intensive effective intervention first, and referring to specialist care when needed. Digital delivery of CBT/ERP is a key development within this approach. Digital interventions may be particularly useful when specialist services are scarce, when travel is difficult, or when young people prefer structured, technology-enabled formats. More recent feasibility and adaptation research has also extended digital delivery to related disorders, including adolescent BDD, suggesting the potential for broader dissemination across OCRDs (Rautio et al., 2023). The evidence base for digital interventions in paediatric OCD is growing, but implementation requires careful attention, safety monitoring, suitability screening (e.g., risk level, complexity, comorbidity), and pathways for escalation. Digital interventions currently should be seen as a complement to, not a replacement for, specialist care—particularly for complex, severe, or high-risk cases, pending more research and studies.
Digitally delivered CBT/ERP and stepped-care models may expand access but require robust clinical pathways and escalation options.
Adapting care for neurodivergent young people, including autism
OCD frequently co-occurs with neurodevelopmental conditions. For autistic young people, OCD symptoms may be harder to differentiate from restricted interests, sensory-driven routines, or insistence on sameness. Standard CBT materials may require adaptation to match communication style, cognitive flexibility, sensory needs, and motivational profiles. Emerging research and clinical protocols emphasise practical adaptations, including increased use of visual supports, concrete language, slower pacing, attention to sensory sensitivities during exposures, and collaborative work with caregivers and schools. Clinical trials are ongoing for therapist-guided digital CBT for OCD in autistic children, reflecting increasing focus on scalable, tailored interventions (Musich & Aragón-Daud, 2022; Spain et. al., 2022)
Neurodevelopmental differences can affect presentation and treatment response; thoughtful adaptations improve accessibility and engagement.
Conclusion
Childhood-onset OCD and related disorders are frequent, potentially impairing conditions with effective evidence-based treatments. Current research has refined understanding of risk factors and longer-term outcomes, while advancing scalable treatment approaches designed to address access gaps. ERP-based CBT remains first-line treatment, with SSRIs often used for more severe or complex presentations. As services respond to rising demand, stepped-care pathways and digital treatments offer promising routes to expand access to care, particularly when combined with robust risk management, clear escalation pathways, and adaptations for neurodivergent young people, including those with autism.
Where next?
We are are delighted to have Professor David Mataix-Cols, present a webinar, OCD; An update on OCD and related disorders in children and young people, where he will will provide an up-to-date overview of the latest research on OCD and related disorders, with a focus on risk factors (e.g. genetics, childhood infections, bullying and traumatic experiences), consequences (e.g. health and socioeconomic outcomes) and evolving clinical approaches in the assessment and treatment of these disorders.
References
Agency for Healthcare Research and Quality. (2024). Diagnosis and management of obsessive-compulsive disorder and related disorders (Comparative Effectiveness Review No. 276). AHRQ.
Carmichael, A., et al. (2021). Long-term outcomes associated with obsessive-compulsive disorder: A population-based study. JAMA Psychiatry.
ClinicalTrials.gov. (2024). ICBT for OCD in children with autism (NCT06582225).
Fernández de la Cruz, L., et al. (2020). Obsessive-compulsive disorder and long-term outcomes across health and functioning: Evidence from population-based cohorts. Molecular Psychiatry.
National Institute for Health and Care Excellence (NICE). (2022). Obsessive-compulsive disorder and body dysmorphic disorder: Treatment (CG31). NICE.
Musich, F., & Aragón-Daud, A. . (2022). Adaptaciones de las terapias psicológicas para adultos con Trastornos del Espectro Autista sin Discapacidad Intelectual. Vertex Revista Argentina De Psiquiatría, 33(157, jul.-sept.), 44–50. https://doi.org/10.53680/vertex.v33i157.266
Pol-Fuster, J., Kuja-Halkola, R., Fernández de la Cruz, L., et al. (2024). Association between severe childhood infections and subsequent risk of OCD is largely explained by shared familial factors. BMJ Mental Health, 27(1), e301203.
Rautio, D., et al. (2023). Therapist-guided, internet-delivered cognitive behaviour therapy for adolescents with body dysmorphic disorder: A feasibility trial. The Lancet Regional Health – Europe.
Shahidullah, J. D., et al. (2023). State of the evidence for use of psychotropic medications in children and adolescents. Psychiatric Clinics of North America.
Spain, D., Musich, F. M., & White, S. W. (Eds.). (2022). Psychological therapies for adults with autism. Oxford University Press.
Zhang, T., Brander, G., Isung, J., et al. (2023). Prenatal and early childhood infections and subsequent risk of obsessive-compulsive disorder and tic disorders: A nationwide, sibling-controlled study. Biological Psychiatry, 94(8), 615–623.
