When No One Claims the Case: OCD, Neurodiversity, and the Marginalised Child

The child has a formal diagnosis of some form of neurodevelopmental disorder—perhaps autism, ADHD, or an intellectual disability. And they also seem to have OCD: intrusive thoughts, rituals, fears of contamination, a need for symmetry or order, a life increasingly dictated by anxiety and compulsion.

The neurodevelopmental service won’t touch them.

“It’s mental health—this is CAMHS.”

CAMHS clinicians say, “Well, they’re autistic—these behaviours aren’t true OCD.”

And so, no one claims the case.

A Child Between Categories

This happens far more often than it should. Children who straddle neurodevelopmental and mental health diagnoses are routinely excluded, misread, or passed around services without anyone taking full ownership of their care. Their distress is either over-psychologised or under-interpreted. The result is the same: a child in pain who doesn’t fit the model.

But we must be careful. Because behind the service confusion is a clinical misunderstanding.

Not All Repetition is OCD

One of the most important distinctions to make—clinically, symbolically, and developmentally—is this:

Not all repetitive behaviours are obsessive-compulsive.

Many neurodivergent young people engage in repetitive, rigid, or ritualistic behaviour. This might serve a range of sensory, regulatory, or organisational functions. It helps them manage change, reduce sensory overload, or provide a felt sense of order. These behaviours can look OCD-like—but they may not involve the same internal experience of obsessional terror, magical thinking, or ego-dystonic intrusion.

A child with autism might line up their toys to soothe visual overload or rewatch the same clip 15 times to regulate internal chaos. The function is regulatory, not symbolic. The drive is sensory, not moral. There may be no associated intrusive thought, no fantasy of consequence, no inner collapse. The repetition is rhythmic, not persecutory.

In contrast, a child with OCD is typically:

• Haunted by a thought or image they can’t bear

• Driven to perform a mental or physical act to neutralise that thought

• Engulfed by shame, guilt, or a fear of moral danger

• Aware, painfully, that the behaviour “makes no sense”—and yet compelled to do it

To confuse these presentations is to miss the structure beneath the surface.

Some Children Have Both

And here’s the further complexity: some children have both.

An autistic child may also have true OCD—just as they may also experience depression, trauma, or psychosis. Autism doesn’t cancel out the rest of mental health. And yet, too often, the moment autism is mentioned, the formulation stops. The symbolic task is dropped. The child’s distress is framed as “just their autism.”

But OCD in autistic young people often looks different. They may:

• Struggle to describe intrusive thoughts with metaphor or abstraction

• Experience the thought as literally true, not symbolically charged

• Feel unable to distance themselves from the thought, even internally

• Be hyper-literal about rules, morality, or consequence

• Seek safety through systems, not relationship

If we interpret them only through a neurodevelopmental lens, we risk ignoring their pain. If we interpret them only through a neurotypical OCD lens, we may miss the way structure, sensory processing, and literal thinking shape the symptom.

What Can Help?

For autistic young people with OCD, a different kind of listening is required. Interventions may still include CBT or medication, but they must be symbolically attuned, developmentally paced, and grounded in structure without demand.

Some principles that help:

• Slow the work of symbolisation. Use visual metaphors, narrative drawing, or mapping to help the child name what the thought is doing—not just what it says.

  
  

• Respect regulatory function. Some rituals may contain sensory meaning or trauma organisation. Not every compulsion should be confronted with exposure on Day One.

  
  

• Track moral anxiety. Literal, black-and-white thinking can turn small infractions into imagined catastrophes. The child may need help understanding the difference between thought and action.

  
  

• Hold clinical responsibility when services won’t. When children fall between the cracks, clinicians must often hold the case longer, bridge systems, and formulate across multiple models. This isn’t a flaw in practice—it’s a necessity of care.

Final Thought

When no one claims the case, we must.

These are the children who are most at risk of slipping into silence—missed, mislabelled, and misunderstood. But if we listen structurally, not just diagnostically, we begin to see what the symptom is doing, not just what it resembles. And that’s when real therapeutic work begins.

Because at the heart of all this is still a frightened child.

Not a category.