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Obsessive-Compulsive Disorder (OCD) 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

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Obsessive-compulsive disorder is characterized by obsessions, compulsions, or both. Obsessions are irresistible, persistent ideas, images, or impulses to do something. Compulsions are pathologic urges to act on an impulse, which, if resisted, result in excessive anxiety and distress. The obsessions and compulsions cause great distress and interfere with academic or social functioning. Diagnosis is by history. Treatment is with behavioral therapy and SSRIs.

(See also Obsessive-Compulsive Disorder in adults.)

Mean age of onset of obsessive-compulsive disorder (OCD) is 19 to 20 yr; about 25% of cases begin before age 14.

OCD encompasses several related disorders, including

Some children, particularly boys, also have a tic disorder.

Etiology

Studies suggest that there is a familial component. However, no specific genes have been identified, although animal studies suggest an abnormality in the genes that affect the function of microglia.

Although some experts remain unconvinced, there is evidence that some cases with acute (overnight) onset have been associated with infection (1, 2). Those associated with group A beta-hemolytic streptococci are called PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcus). Those associated with other infections are called PANS (pediatric acute-onset neuropsychiatric syndrome).

Research in this area is ongoing, and if PANDAS or PANS is suspected, consultation with a specialist in these disorders is recommended.

Etiology references

  • 1. Murphy TK, Roger Kurlan R, James Leckman J: The immunobiology of Tourette's disorder, pediatric autoimmune neuropsychiatric disorders associated with Streptococcus, and related disorders: A way forward. J Child Adolesc Psychopharmacol 20 (4):317–331, 2010. doi: 10.1089/cap.2010.0043.

  • 2. Esposito S, Bianchini S, Baggi E, Fattizzo M, Rigante D: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: An overview. Eur J Clin Microbiol Infect Dis 33 (12):2105–2109, 2014.

Symptoms and Signs

Typically, OCD has a gradual, insidious onset. Most children initially hide their symptoms and report struggling with symptoms years before a definitive diagnosis is made.

Obsessions are typically experienced as worries or fears of harm (eg, contracting a deadly disease, sinning and going to hell, injuring themselves or others). Compulsions are deliberate volitional acts, usually done to neutralize or offset obsessional fears; they include checking behaviors; excessive washing, counting, or arranging; and many more. Obsessions and compulsions may have some logical connection (eg, handwashing to avoid disease) or may be illogical and idiosyncratic (eg, counting to 50 over and over to prevent grandpa from having a heart attack). If children are prevented from carrying out their compulsions, they become excessively anxious and concerned.

Most children have some awareness that their obsessions and compulsions are abnormal. Many affected children are embarrassed and secretive. Common symptoms include

  • Having raw, chapped hands (the presenting symptom in children who compulsively wash)

  • Spending excessively long periods of time in the bathroom

  • Doing schoolwork very slowly (because of an obsession about mistakes)

  • Making many corrections in schoolwork

  • Engaging in repetitive or odd behaviors such as checking door locks, chewing food a certain number of times, or avoiding touching certain things

  • Making frequent and tedious requests for reassurance, sometimes dozens or even hundreds of times per day—asking, eg, “Do you think I have a fever? Could we have a tornado? Do you think the car will start? What if we’re late? What if the milk is sour? What if a burglar comes?”

Diagnosis

  • Clinical evaluation

Diagnosis of OCD is by history. Once a comfortable relationship with a nonjudgmental therapist is established, the child with OCD usually discloses many obsessions and related compulsions. However, usually several appointments are needed to first establish trust.

For OCD to be diagnosed, the obsessions and compulsions must cause great distress and interfere with academic or social functioning.

Children with OCD often have symptoms of other anxiety disorders, including panic attacks, separation problems, and specific phobias. This symptom overlap sometimes confuses the diagnosis.

Diagnostic criteria for PANDAS and PANS have been developed (1, 2).

Diagnosis references

  • 1. Chang K, Frankovich J, Cooperstock M, et al: Clinical evaluation of youth with pediatric acute-onset neuropsychiatric syndrome (PANS): Recommendations from the 2013 PANS Consensus Conference. J Child Adolesc Psychopharmacol 25 (1):3–13, 2015. doi: 10.1089/cap.2014.0084.

  • 2. Swedo S, Leckman J, Rose N: From research subgroup to clinical syndrome: Modifying the PANDAS criteria to describe PANS (pediatric acute-onset neuropsychiatric syndrome). Pediatr Therapeutics 2:1–8, 2012.

Prognosis

In about 5% of children, the disorder remits after a few years, and in about 40%, it remits by early adulthood. Treatment can then be stopped. In other children, the disorder tends to be chronic, but normal functioning can usually be maintained with ongoing treatment. About 5% of children do not respond to treatment and remain greatly impaired.

Treatment

  • Cognitive-behavioral therapy

  • Usually SSRIs

Cognitive-behavioral therapy is helpful if children are motivated and can carry out the tasks.

SSRIs are the most effective drugs and are generally well-tolerated (see Table: Drugs for Long-Term Treatment of Anxiety and Related Disorders); all are equally effective. However, about 50% of patients respond only partially to SSRIs and may require an SSRI plus other drugs that have serotonergic activity (eg, lithium) or glutamatergic activity (eg, riluzole). Another alternative is clomipramine, a tricyclic antidepressant, which may be more effective and have a better response rate than SSRIs, although it has a higher risk of cardiac effects and seizures.

If criteria for PANS/PANDAS are met, clinicians may try antibiotics (such as beta-lactams, which reduce glutamatergic activity). However, if symptoms persist, the typical treatments for OCD are helpful and should be implemented.

Key Points

  • Children typically experience obsessions as worries or fears of harm (eg, contracting a deadly disease, sinning and going to hell, injuring themselves).

  • Compulsions (eg, excessive washing, counting, arranging) are done deliberately, usually to neutralize or offset obsessional fears.

  • Not being able to carry out their compulsions makes children excessively anxious and concerned.

  • Establish a comfortable relationship with the child and maintain a nonjudgmental attitude so that the child feels able to disclose obsessions and related compulsions.

  • Try cognitive-behavioral therapy if children are motivated and can carry out the tasks, but drugs (usually SSRIs) may be needed.