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Obsessive-Compulsive Disorder and Related Disorders in Children and Adolescents

By Josephine Elia, MD, Professor of Psychiatry and Human Behavior, Professor of Pediatrics;Attending Physician, Sidney Kimmel Medical College of Thomas Jefferson University;Nemours/A.I. duPont Hospital for Children

Obsessive-compulsive disorder is characterized by recurring, unwanted, intrusive doubts, ideas, images, or impulses (obsessions) and unrelenting urges to do actions (compulsions) to try to lessen the anxiety caused by the obsessions. The obsessions and compulsions cause great distress and interfere with school and relationships.

  • Obsessions often involve worry or fear of being harmed or of loved ones being harmed (for example, by illness, contamination, or death).

  • Compulsions are excessive, repetitive, purposeful behaviors that children feel they must do to manage the doubts (for example, by repeatedly checking to make sure a door is locked), to prevent something bad from happening, or to reduce the anxiety caused by their obsessions.

  • Behavioral therapy and drugs are often used in treatment.

On average, obsessive-compulsive disorder (OCD) begins at about age 19 to 20 years, but over 25% of cases begin before age 14. The disorder often lessens after children reach adulthood.

Obsessive-compulsive disorder includes several related disorders, including

Some children, particularly boys, also have a tic disorder (see Tourette Syndrome and Other Tic Disorders in Children and Adolescents).

Genes and environmental factors are thought to cause OCD. Studies to identify the genes are being done. Infections may be involved in a few cases that begin suddenly. If streptococci are involved, the disorder is called pediatric autoimmune neuropsychiatric disorder associated with streptococci (PANDAS). If other infections (such as Mycoplasma pneumoniae infection) or other conditions (such as stresses) are involved, the disorder is called pediatric acute-onset neuropsychiatric syndrome (PANS).


Typically, symptoms develop gradually, and most children can hide their symptoms at first.

Children are often obsessed with worries or fears of being harmed—for example, of contracting a deadly disease or of injuring themselves or others. They feel compelled to do something to balance or neutralize their worries and fears. For example, they may repeatedly do the following:

  • Check to make sure they turned off their alarm or locked a door

  • Wash their hands excessively, resulting in raw, chapped hands

  • Count various things (such as steps)

  • Sit down and get up from a chair

  • Constantly clean and arrange certain objects

  • Make corrections in schoolwork

  • Chew food a certain number of times

  • Avoid touching certain things

  • Make frequent requests for reassurance, sometimes dozens or even hundreds of times per day

Some obsessions and compulsions have a logical connection. For example, children who are obsessed with not getting sick may wash their hands very frequently. However, some are totally unrelated. For example, children may count to 50 over and over to prevent a grandparent from having a heart attack. If they resist the compulsions or are prevented from carrying them out, they become extremely anxious and concerned.

Most children have some idea that their obsessions and compulsions are abnormal and are often embarrassed by them and try to hide them. In many children, the disorder tends to be chronic.


  • Symptoms

Doctors based the diagnosis on symptoms. Several visits may be needed before children with OCD trust a doctor enough to tell the doctor their obsessions and compulsions.


  • Behavioral therapy

  • Sometimes drugs

Behavioral therapy, if available, may be all that is needed if children are highly motivated.

If needed, a combination of behavioral therapy and a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI—see Table: Drug therapy for depression) is usually effective. This combination enables most children to function normally. If SSRIs are ineffective, doctors may prescribe clomipramine, another type of antidepressant. However, it can have serious side effects.

For some children, behavioral therapy can cure the disorder. A few children do not respond to treatment and remain greatly impaired. They may need to be treated as inpatients in a facility where intensive behavioral therapy can be done and drugs can be managed.

If streptococcal infection is involved, antibiotics are used.