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

By

Josephine Elia

, MD, Sidney Kimmel Medical College of Thomas Jefferson University

Last full review/revision Apr 2021| Content last modified Apr 2021
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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 selective serotonin reuptake inhibitors (SSRIs).

(See also Obsessive-Compulsive Disorder in adults.)

Mean age of onset of obsessive-compulsive disorder (OCD) is 19 to 20 years; about 21% of cases begin before age 10 (1).

OCD encompasses several related disorders, including

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

General reference

  • 1. Kessler RC, Berglund P, Demler O, et al: Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):593-602, 2005. doi: 10.1001/archpsyc.62.6.593

Etiology

Studies suggest that there is a familial component (1). However, no specific genes have been identified, although animal studies suggest an abnormality in the genes that affect the function of microglia. Neuroimaging studies point to a possible issue with the cortico-striatal-thalamic circuits (2).

There is evidence that some cases with acute (overnight) onset have been associated with infection (3, 4). 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). Upregulation and proliferation of "immature" circulating monocytes which can enter the brain and increase the release of proinflammatory cytokines has also been reported to play a role in pediatric OCD (5–7).

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. Hanna GL, Himle JA, Curtis GC, et al: A family study of obsessive-compulsive disorder with pediatric probands. Am J Med Genet B Neuropsychiatr Gen 2005;134B(1):13-19, 2005. doi: 10.1002/ajmg.b.30138 

  • 2. Fitzgerald KD, Welsh RC, Stern ER, et al: Developmental alterations of frontal-striatal-thalamic connectivity in obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 50(9):938-948.e3, 2011. doi: 10.1016/j.jaac.2011.06.011

  • 3. Murphy TK, Kurlan R, 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

  • 4. Esposito S, Bianchini S, Baggi E, et al: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: An overview. Eur J Clin Microbiol Infect Dis 33:2105-2109, 2014.

  • 5. Rodriguez N, Morer A, Gonzalez-Navarro EA, et al: Inflammatory dysregulation of monocytes in pediatric patients with obsessive-compulsive disorder. J Neuroinflammation 14(1):261, 2017. doi: 10.1186/s12974-017-1042-z

  • 6. Wohleb ES, McKim DB, Sheridan JF, et al: Monocyte trafficking to the brain with stress and inflammation: A novel axis of immune-to-brain communication that influences mood and behavior. Front Neurosci 8:447, 2014.

  • 7. Cosco TD, Pillinger T, Emam H, et al: Immune aberrations in obsessive-compulsive disorder: A systematic review and meta-analysis. Mol Neurobiol 56(7):4751-4759, 2019. doi: 10.1007/s12035-018-1409-x

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. The differential diagnosis can be challenging in the following cases:

  • Early-onset psychosis: Unlike adults, children do not always distinguish the unreal nature of the OCD symptoms.

  • Autism spectrum disorder: Intense interests and compulsions can occur in autism. Unlike in OCD, where these may be found intrusive and problematic, children with autism prefer these activities.

  • Complex tic disorders: Complex tics can be difficult to distinguish from compulsions.

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 SE, Leckman JF, Rose NR: From research subgroup to clinical syndrome: Modifying the PANDAS criteria to describe PANS (pediatric acute-onset neuropsychiatric syndrome). Pediatr Therapeutics 2:1-8, 2012. doi: 10.4172/2161-0665.1000113 

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 (CBT): Graded exposure and response prevention (1)

  • Usually selective serotonin reuptake inhibitors (SSRIs; [2])

Cognitive-behavioral therapy is helpful if children are motivated and can carry out the tasks and should be the first-line treatment.

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.

For severe OCD, a combination of SSRI and CBT is recommended (3).

For treatment-refractory OCD, the following strategies could be considered:

  • Trial of a different SSRI

  • Augmentation of the SSRI with an atypical antipsychotic (4–6) or less often lithium (7), riluzole (8), N-acetylcysteine (9, 10)

  • Clomipramine

Clomipramine (11) may be more effective and have a better response rate than SSRIs in children but not adults (12). Clomipramine may have higher risk of adverse effects, including anticholinergic and cardiac adverse effects, and seizures.

Transcranial magnetic stimulation was recently approved for adults by the U.S. Food and Drug Administration, and testing for use in children is in progress.

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.

Treatment references

  • 1. Uhre CF, Uhre VF, Lonfeldt NN, et al: Systematic review and meta-analysis: Cognitive-behavioral therapy for obsessive-compulsive disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry 59(1)59:64-77, 2020. doi: 10.1016/j.jaac.2019.08.480

  • 2. Geller DA, Biederman J, Stewart SE, et al: Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. Am J Psychiatry 160(11):1919-1928, 2003. doi: 10.1176/appi.ajp.160.11.1919

  • 3. Sanchez-Meca J, Rosa-Alcazar AI, Iniesta-Sepulveda M, et al: Differential efficacy of cognitive-behavioral therapy and pharmacological treatments for pediatric obsessive-compulsive disorder: A meta-analysis. J Anxiety Disord 28(1):31-44. doi: 10.1016/j.janxdis.2013.10.007

  • 4. Fitzgerald KD, Stewart CM, Tawile V, et al: Risperidone augmentation of serotonin reuptake inhibitor treatment of pediatric obsessive compulsive disorder. J Child Adolesc Psychopharm 9(2):115-123, 1999. doi: 10.1089/cap.1999.9.115

  • 5. Figueroa Y, Rosenberg DR, Birmaher B, et al: Combination treatment with clomipramine and selective serotonin reuptake inhibitors for obsessive-compulsive disorder in children and adolescents. J Child Adolesc Psychopharmacol 8(1):61-67, 1998. doi: 10.1089/cap.1998.8.61

  • 6. Simeon JG, Thatte S, Wiggins D: Treatment of adolescent obsessive-compulsive disorder with a clomipramine-fluoxetine combination. Psychopharmacol Bull 26(3):285-290, 1990.

  • 7. McDougle CJ, Price LH, Goodman WK, et al: A controlled trial of lithium augmentation in fluvoxamine-refractory obsessive-compulsive disorder: Lack of efficacy. J Clin Psychopharmacol 11(3):175-184, 1991.

  • 8. Grant PJ, Joseph LA, Farmer CA, et al: 12-week, placebo-controlled trial of add-on riluzole in the treatment of childhood-onset obsessive-compulsive disorder. Neuropsychopharmacology 39(6):1453-1459, 2013. doi: 10.1038/npp.2013.343

  • 9. Afshar H, Roohafza H, Mohammad-Beigi HM, et al: N-acetylcysteine add-on treatment in refractory obsessive-compulsive disorder: A randomized, double-blind, placebo-controlled trial. J Clin Psychopharmacol 32(6):797-803, 2012. doi: 10.1097/JCP.0b013e318272677d

  • 10. Sarris J, Oliver G, Camfield DA, et al: N-acetyl cysteine (NAC) in the treatment of obsessive-compulsive disorder: A 16-week, double-blind, randomised, placebo-controlled study. CNS Drugs 29(9):801-809, 2015. doi: 10.1007/s40263-015-0272-9

  • 11. DeVeaugh-Geiss J, Moroz G, Beiderman J, et al: Clomipramine hydrochloride in childhood and adolescent obsessive-compulsive disorder—A multicenter trial. J Am Acad Child Adolesc Psychiatry 31(1):45-49, 1992. doi: 10.1097/00004583-199201000-00008

  • 12. Mundo E, Maina G, Uslenghi C: Multicentre, double-blind, comparison of fluvoxamine and clomipramine in the treatment of obsessive-compulsive disorder. Int Clin Psychopharmacol 15(2):69-76, 2000. doi: 10.1097/00004850-200015020-00002

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.

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