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Obsessive-Compulsive Disorder (OCD) and Related Disorders in Children and Adolescents

by Josephine Elia, MD

Obsessive-compulsive disorder (OCD) 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.

Mean age of onset of 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 (see Tic Disorders and Tourette Syndrome in Children and Adolescents).


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.

Some cases of have been associated with infection. Those associated with group A β-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 is strongly recommended.

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?”


  • Clinical evaluation

Diagnosis 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. 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.


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.


  • 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.

There are no guidelines for the treatment of PANDAS and PANS. Antibiotics that dampen glutamatergic activity (eg, β-lactams) may help in some cases.

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