Is it OCD, ADHD or both?
January 18, 2025
Written by Nikki Pagano, LCSW (OCD , Anxiety and Eating Disorder specialist) & Alyse Bone, LCMHC (ADHD specialist with training in OCD)
“She can’t seem to focus in class and getting her to bed is taking hours,” a mom replies when asked what brings them into my office. Is she distracted, disorganized, worried? Symptoms of obsessive compulsive disorder (OCD) and attention-deficit/ hyperactive disorder (ADHD) can look the same, so understanding what drives the behavior informs diagnosis and treatment. OCD and ADHD are two of the most diagnosed neuropsychiatric disorders and children can often be misdiagnosed or missed diagnosed (being diagnosed with one but having both).
What is OCD and how is it treated?
OCD is a disorder in which a person experiences obsessions – intrusive, unwanted thoughts which increase distress. To decrease the distress, an individual may engage in compulsions, or repetitive behaviors or mental rituals. In a child, this may look like a particular bedtime routine, asking the same question multiple times, or appearing distracted because they are saying a phrase a certain number of times in their head.
The gold standard treatment for OCD is called exposure and response prevention (ERP), a form of CBT, which helps the individual confront their obsessions and tolerate the discomfort while resisting engaging in compulsions. An example of this might be completing a bedtime routine in a different way or resisting asking a question more than once.
What is ADHD and how is it treated?
ADHD is a developmental disorder that impacts a person’s ability to pay attention, specifically related to executive functioning (impulse control, time management, organization, multitasking, planning, transitioning, shifting, and emotional regulation). A person can be predominantly inattentive, they experience difficulty with attention or hyperfocus, or predominantly hyperactive/impulsive, they experience an inability to sit still. Lastly, an individual can be diagnosed as “combined type,” meaning they experience both hyperactivity and inattentiveness.
Effective treatment for ADHD in children may involve medication management, CBT, and parent training (depending on the child’s age).
How do we know if it’s OCD, ADHD or both?
Surprisingly, a combined diagnosis of OCD and ADHD are more common than you might think. Research tells us that 12-25% of individuals with OCD also have a diagnosis of ADHD, and about 8% of children with ADHD also meet criteria for OCD.
However, because OCD and ADHD symptoms can look similar, individuals may be misdiagnosed. Both disorders impact an individual’s ability to concentrate and may impair executive functioning. An individual with ADHD may not have the ability to engage in non-preferred tasks whereas an individual with OCD may become so distracted by intrusive, distressing thoughts that they are not able to focus on the task at hand. There are important differences in these diagnoses. ADHD is considered an externalizing disorder – the disorder impacts how the individual relates to their external environment – while OCD is thought of as an internalizing disorder – meaning individuals respond to changes in their environment by turning inward.
Similarities distinguished between the two diagnoses include:
Impulsivity vs Compulsions
Both involve a sense of urgency or inability to resist a behavior.
Impulsivity is seen in ADHD and may look like acting without thinking, blurting out answers, or interrupting others. Compulsions are seen in OCD and may look like repetitive behaviors or distraction caused by mental rituals performed in order to alleviate distress.
Inattention vs Obsessive Thoughts
Inattention is a key feature in children with ADHD which may look like difficulty sustaining focus and being easily distracted. Children with OCD experience intrusive and persistent thoughts, images, or urges (obsessions) that increase anxiety and / or distress and interfere with their ability to concentrate on tasks.
Deficit in Organizational Skills vs Ritualistic Behavior
Children with ADHD may have difficulty with organization, planning, and completing tasks, which can lead to disorganization and chaos. Children with OCD may engage in rituals or routines to alleviate anxiety. These rituals may involve specific and rigid patterns of behavior, such as arranging objects in a particular order which may appear disorganized to others. Changing the arrangement or order typically causes distress to the child. .
How does treatment work when both are present or you’re unsure if it’s OCD or ADHD?
The treatment team for a child with OCD, ADHD or both may include a mental health therapist and a psychiatric prescriber. The psychiatrist provides medication recommendations and management, while the therapist works closely with child and parents (depending on the age), teaching skills and parenting interventions to reduce the frequency and distress related to OCD and ADHD symptoms. An important part of therapeutic treatment is practicing these skills and interventions between sessions. In seeking out your treatment team, it is important to identify therapists that specialize in evidence-based treatments for these disorders, specifically a therapist who provides exposure and response prevention for OCD and a therapist that provides behavioral interventions including a parent component and social skills groups if needed for ADHD.
Your providers will help you determine if treatment will work best by focusing on both diagnoses at once or staging out treatment to see if ADHD-like symptoms resolve once OCD symptoms are treated. From a medication perspective, research supports that individuals with OCD benefit from an SSRI while individuals with ADHD benefit from a stimulant. Monitoring progress of treatment with standardized measures allows clinicians to identify which areas have improved or are worsening to determine the effectiveness of therapeutic interventions and medication treatment.
Helpful Resources
