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 their 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.
(See also Overview of Anxiety Disorders in Children and Adolescents and Obsessive-Compulsive Disorder in adults.)
On average, obsessive-compulsive disorder (OCD) begins at about age 19 to 20 years, but about 25% of cases begin before age 14. The disorder often lessens after children reach adulthood.
Obsessive-compulsive disorder includes several related disorders:
Body dysmorphic disorder: Children become preoccupied with an imagined defect in appearance, such as the size of their nose or ears, or become excessively concerned with a slight abnormality, such as a wart.
Hoarding: Children have a strong need to save items regardless of their value and cannot tolerate parting with the items.
Trichotillomania (hair pulling)
Some children, particularly boys, also have a tic disorder.
Genes and environmental factors are thought to cause OCD. Studies to identify the genes are being done.
There is some evidence that infections may be involved in a few cases of OCD that begin suddenly (overnight). If streptococci are involved, the disorder is called pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS). If other infections (such as Mycoplasma pneumoniae infection) are involved, the disorder is called pediatric acute-onset neuropsychiatric syndrome (PANS). Researchers continue to study the connection between infections and OCD.
Typically, symptoms of OCD 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 many 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. However, some children strongly believe that their obsessions and compulsions are valid.
OCD resolves after a few years in about 5% of children and by early adulthood in about 40%. In other children, the disorder tends to be chronic, but with continuing treatment, most children can function normally. About 5% of children do not respond to treatment and remain greatly impaired.
Doctors base the diagnosis of OCD on symptoms. Several visits may be needed before children with OCD trust a doctor enough to tell the doctor their obsessions and compulsions.
For OCD to be diagnosed, the obsessions and compulsions must cause great distress and interfere with the child's ability to function.
If doctors suspect that an infection (such as PANDAS or PANS) may be involved, they usually consult with a specialist in these disorders.
Great care must be taken to differentiate OCD from other disorders, such as early-onset psychosis, autism spectrum disorders, and complex tic disorders.
Cognitive-behavioral therapy, if available, may be all that is needed if children are highly motivated.
If needed, a combination of cognitive-behavioral therapy and a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI) is usually effective for OCD. 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. Other options are available if these do not work.
If treatment is ineffective, children 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 (PANDAS) or another infection (PANS) is involved, antibiotics are usually used. If needed, cognitive-behavioral therapy and the drugs typically used to treat OCD are also used.
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