Obsessive-Compulsive Disorder and Related Disorders in Children and Adolescents

Studies suggest that there is a familial component (1).

There is evidence that some cases with acute (overnight) onset have been associated with infection (2, 3). 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). Frequency of new cases for OCD and tics was higher in 5 to 11 year olds infected with COVID-19 compared to those not infected (4). Upregulation and proliferation of "immature" circulating monocytes, which have been suspected to enter the brain and increase the release of proinflammatory cytokines, has also been reported to play a role in pediatric OCD (5, 6).

If PANDAS or PANS is suspected, consultation with a specialist in these disorders is recommended.

Perinatal trauma (eg, in utero drug or alcohol use, mechanically assisted delivery) has also been implicated in the pathogenesis of OCD (7).

The gene networks of OCD are highly complex and include those involved in synaptic transmission, neurodevelopment, and immune and inflammatory systems (1). Linkage analysis has implicated defects in the glutamate transporter SLC1A1 and flanking regions on chromosome 9, as well as the glutamate receptor GRIN2B. Additive effects stemming from other/multiple genetic loci may compound the severity of OCD (2). Neuroimaging studies point to possible dysfunction within the cortico-striatal-thalamic circuits (3).

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 involuntary worries or fears of harm (eg, contracting a deadly disease, 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 can 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 typical 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?”

• Psychiatric assessment

• Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, Text Revision (DSM-5-TR) criteria

Diagnosis of OCD is based on clinical 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. The developmental context must be taken into consideration when evaluating young children with suspected OCD.

A diagnosis of OCD requires that the obsessions and compulsions cause great distress and interfere with academic and/or social functioning (1). Associated familial anxiety must also be screened for in the parents or caregivers and appropriate referrals or management should be instituted.

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.

• Tourettic OCD: Tourettic OCD is a distinct neuropsychiatric disorder that combines features of both Tourette syndrome and OCD (2). While children with Tourettic OCD may exhibit compulsions, traditional obsessions are rare in this subtype. Instead, a significant physical discomfort often drives compulsions in Tourettic OCD, making it important to recognize and treat both the tic symptoms of Tourette syndrome and the compulsive behaviors associated with OCD.

Diagnostic criteria for PANDAS (1 criterion is the presence of symptoms of OCD or a tic disorder) and PANS (1 criterion is abrupt, dramatic onset of OCD or severely restricted food intake) have been developed (3, 4).

• Cognitive-behavioral therapy (CBT) with graded exposure and response prevention

• Usually selective serotonin reuptake inhibitors (SSRIs)

• Sometimes clomipramine or antipsychoticsSometimes clomipramine or antipsychotics

For most patients with OCD, CBT, SSRIs, and clomipramine are all effective treatment options. Exposure and response prevention is the most effective behavioral form of CBT in OCD and should be the first-line treatment (For most patients with OCD, CBT, SSRIs, and clomipramine are all effective treatment options. Exposure and response prevention is the most effective behavioral form of CBT in OCD and should be the first-line treatment (1). Exposure and response prevention focuses on exposing the child to the anxiety-inducing situation and coaching them to abstain from responding with compulsive behaviors. It is helpful if children are motivated and can carry out the tasks; it is also important to include primary caregivers to provide support and training for them in managing their child's rituals.

CBT, used alone or with an SSRI, is likely more effective than SSRIs used alone (2).

SSRIs (those with and without FDA approval) are the most effective medications and are generally well tolerated (see table Medications For Long-Term Treatment of Anxiety, Depression, 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 () or less often lithium (7), riluzole (), riluzole (8), N-acetylcysteine ), N-acetylcysteine(9, 10)

• ClomipramineClomipramine

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.). Clomipramine may have higher risk of adverse effects, including anticholinergic and cardiac adverse effects, and seizures.

For Tourettic OCD, a combination of SSRI for OCD and alpha-adrenergic agonists or antipsychotics may be needed, in addition to habit reversal therapy (HRT) for tics (13).

Transcranial magnetic stimulation is another effective treatment approved for ages 18 and above by the FDA; 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) even if there is no evidence of infection (14). However, if symptoms persist, the typical treatments for OCD are helpful and should be implemented.

The long-term outcome of pediatric OCD is generally positive when diagnosed and treated early. However, a substantial minority (approximately 40%) of cases persist into adulthood (1), and the clinical course is often variable with exacerbations and remissions. In 1 meta-analysis, the remission rate of pediatric OCD was 62%, with shorter duration of illness at baseline predicting higher rates of remission (2). Comorbid conditions like PANDAS and PANS can influence the severity and course of the disorder.