Identifying details in this case have been changed. The clinical pattern is presented with consent, in a form that could not identify the child or family.
Aarav was eight when his class teacher first wrote to his parents. He was bright, she said, and kind to the other children. But he had started arriving late, and once he arrived he did not always come in. Some mornings he stood at the classroom door for ten minutes, looking up.
He was counting the ceiling tiles.
What the referral said, and what it missed
The referral letter used the word “obsessive.” It is an easy word to reach for. A child performs a repetitive act, appears distressed when interrupted, and the label arrives before the question does. But obsessive-compulsive disorder has a particular architecture: an intrusive thought that causes distress, and a behaviour performed to neutralise it. The behaviour is not wanted. It is a tax the child pays to a thought they did not choose.
When I asked Aarav what would happen if he did not count, he looked genuinely puzzled. “Nothing,” he said. “I just wouldn’t be ready yet.”
That sentence reorganised the case.
Counting as a regulation strategy
Aarav was not neutralising a feared outcome. He was buying time. Counting gave him a structured, predictable, entirely controllable task to perform in a doorway that had become, for reasons we had not yet found, unbearable to walk through. The ceiling tiles were the same every day. The classroom was not.
This distinction matters enormously for treatment. Exposure and response prevention — the front-line approach for OCD — would have meant stopping him from counting and sitting with the resulting anxiety. Had we done that, we would have removed the only regulation strategy an eight-year-old had built for himself, without giving him another one, and we would have called the resulting collapse “treatment resistance.”
A behaviour is not a symptom until you know what it is doing. Until then it is a solution, and the child usually understands it better than you do.
Finding the door
Three sessions in, working with drawings rather than questions, the reason surfaced. Two months earlier a boy in his class had had a seizure during a maths lesson. Aarav had been sitting beside him. The adults in the room had acted quickly and correctly, and afterwards nobody had explained anything to the children, because nothing bad had ultimately happened.
Aarav had concluded that classrooms were places where people suddenly stopped being alright, and that he would not be told when it was about to happen. The counting was the last stretch of a world where he knew what came next.
What we actually did
The work had three strands, and only one of them was with Aarav.
- Information. A short, accurate, age-appropriate explanation of what a seizure is, given by the school nurse to the whole class, not privately to Aarav. Anxiety in children is very often a gap where an explanation should have been.
- Predictability, deliberately built. His teacher began writing the shape of the morning on the board before the children came in. Aarav was given a job — handing out the reading folders — that meant he had a reason to enter the room and something to do in the first sixty seconds.
- Gradual retirement of the counting. Not prohibition. We moved it: first to the corridor before the door, then to the walk down the corridor, then to a small object in his pocket he could touch instead. It faded on its own by week nine because it was no longer needed.
Where he is now
Aarav still counts occasionally — before exams, before a class trip. His parents were initially alarmed by this. I think it is the most reassuring part of the case. He has kept a tool and learned to reach for it deliberately rather than compulsively, which is roughly the definition of a coping strategy.
What I take from this
Three things, which I keep returning to:
The form of a behaviour tells you very little about its function. Counting, checking, rocking, tapping, arranging — the same observable act serves entirely different purposes in different children, and the purpose is what you treat.
Ask the child what would happen if they stopped. It takes eleven seconds and it is often the single most diagnostically useful question in the assessment.
A lot of childhood anxiety is environmental, and the environment is more treatable than the child. We spent more clinical time with the teacher than with Aarav, and that was the right allocation.
If you work with children and are reading this as a professional: the differential between OCD and anxiety-driven ritualisation in under-tens is genuinely difficult, and the literature is thinner than you would hope. I would rather over-assess and under-label at this age.