Pediatric Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a neurobiologic disorder that can severely disrupt academic, social, and vocational functioning.[1]  The major features of this disorder are the presence of recurring obsessions (recurrent unwanted thoughts, urges, or images) and compulsions (repetitive excessive actions that interfere with a person's life).[2]  (See Etiology, History.) If OCD is suspected, referral to a mental health professional is indicated.[2] (See Epidemiology.)

Go to Pediatric Generalized Anxiety Disorder and Pediatric Panic Disorder for complete information on these topics.

Obsessions and compulsive behaviors

Obsessions are defined as recurrent and persistent thoughts, images, or impulses that are ego-dystonic, intrusive, and, for the most part, acknowledged as senseless.[3]  Obsessions usually are accompanied by dysphoric affect, such as fear, doubts, and disgust.[2]

Children and adolescents with OCD typically first try to ignore, suppress, or deny obsessive thoughts and may not report the symptoms as ego-dystonic or senseless. However, by trying to neutralize excessive thoughts, individuals with OCD very quickly change their behaviors by performing some type of compulsive actions, which are repetitive, purposeful behaviors carried out in response to the obsession. Usually, these repetitive actions follow certain rules or are quite stereotyped.

Some compulsions observed include behaviors such as washing, counting, or lining up of objects. Other compulsions are covert mental acts, such as counting or reading a passage again and again.[3]  Thus compulsions as mental rituals may not be apparent to those around the patient; patients may hide their compulsions from others. These compulsions serve to reduce the anxiety produced by the obsessive thoughts. If something interferes with or blocks the compulsive behavior, the child feels heightened anxiety or fear and can become quite upset and oppositional. (See History.)

OCD versus normal ritualistic behaviors

Not confusing OCD with normal ritualistic behavior of childhood is important. Most children exhibit typical, age-dependent, compulsive behaviors. Frequently, young children prefer that events occur in a particular way, they insist on specific bedtime or mealtime rituals, and they become distressed if these rituals are disrupted.

Cross-sectional research of ritualistic behavior in children demonstrates that these behaviors appear when the individual is aged approximately 18 months, peak when the individual is aged approximately 2–3 years, and decline afterward. Presence of these behaviors appears to be related to mental age; thus, children with cognitive levels at a developmental age of 2–3 years may have higher rates of compulsive behaviors, which are appropriate to their cognitive levels of development. These behaviors are best understood by acknowledging that they involve mastery and control of their environment, and, usually, they decrease to low levels by middle childhood. As a child ages, compulsive behaviors are replaced by hobbies or focused interests.

Normative compulsive behaviors can be discriminated from OCD on the basis of content, timing, and severity. Normative compulsive behaviors do not interfere with daily functioning.[4]

Mortality in OCD

One of the leading causes of death of patients with OCD is suicide. A population study in Sweden demonstrated that patients with OCD have a markedly increased risk of suicide.[5]

Patient education

For patient education information, see the Anxiety Center, as well as Anxiety, Panic Attacks, and Hyperventilation.

Obsessive-compulsive disorder (OCD) is considered a neuropsychiatric disorder. OCD symptoms do not appear to represent intrapsychic conflicts within individuals. Indeed, relatively few OCD behaviors exist, and they are experienced in much the same manner by patients, regardless of their interpersonal histories.[6]

Initial successes in treatment of OCD with selective serotonin reuptake inhibitors (SSRIs) have led to a neuropsychiatric explanation of a serotonin-mediated "grooming behavior" that has been disrupted. In addition, clear family genetic studies demonstrate that, in some cases, OCD and Tourette syndrome may represent expressions of the same gene. Tic disorders occur more frequently in individuals who have OCD, and first-degree relatives of patients with OCD have higher rates of tic disorders, Tourette syndrome (TS), and OCD. While there exists some overlap in the genetic basis of OCD and TS, the conditions represent two unique genetic structures.[7]

OCD may result from excessive glutamatergic activity in the prefrontal and orbitofrontal cortex.[8, 9, 10]

Neuroimaging studies suggest abnormalities in neurologic circuits that link cortical areas to the basal ganglia. These circuits appear to change in response to successful treatment with either SSRI medication or cognitive behavior therapies (CBTs). Increased emotional processing-related activation has been demonstrated in limbic, frontal, and temporal regions.[11] Also, neurotransmitter and neuroendocrine abnormalities have been documented in childhood-onset OCD. Anti-basal ganglia antibodies had been shown to be five times more likely to be detected in the serum of individuals with primary OCD in comparison with healthy controls, and patients with various psychiatric, neurological, and autoimmune disorders.[12]

In addition, investigators have found OCD symptoms that arise from, or are strongly exacerbated in, the context of group A beta-hemolytic streptococcal (GABHS) infection. Such conditions are referred to as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) characterized by a sudden exacerbation of OCD symptoms in the presence of an upper respiratory tract illness caused by antineuronal antibodies formed against group A beta-hemolytic streptococcal cell wall antigens, which cross-react with caudate neural tissue and initiate OCD symptoms. [13, 14]

Incidence

In the United States, obsessive-compulsive disorder (OCD) has a 6-month prevalence of approximately 1 in 200 children and adolescents, while the prevalence of OCD occurring at any time during childhood is assumed to be 2–3 per 100 children.[15]

Among adults with OCD, interview data indicate that one third to one half developed the disorder during childhood. Unfortunately, this disorder often goes unrecognized in children and adolescents. Onset in childhood or adolescence can lead to a lifetime of OCD. However, 40% of individuals with early onset may experience remission by early adulthood.[2, 16]

Race predilection

There are no differences in prevalence as a function of ethnic group or geographic region.

Sex predilection

Boys are more likely to have a prepubertal onset and a family member with OCD or Tourette syndrome. Girls are more likely to have onset of OCD during adolescence.

Age predilection

OCD has been studied most comprehensively at the National Institute of Mental Health with referred patients, who likely represent more severe cases. In those studies, the modal age of onset was 7 years; the mean age was 10.2 years. These figures imply the possible existence of an early-onset group in childhood and a second group with onset in adolescence.[17]

Family History

Since OCD tends to run in families, people with relatives who have OCD are vulnerable to develop OCD.[18]

No specific predictors of treatment outcome have been identified for pediatric obsessive-compulsive disorder (OCD). Children who can identify their obsessions as senseless and their rituals as useless and distressing are candidates for cognitive-behavioral therapy (CBT). A calm, supportive family environment in which parents and/or caregivers actively can support the child's coping strategies also should improve outcome.[19]  Pediatric OCD appears to have a better prognosis than adult-onset OCD.[20]  

Comorbidity of OCD with other disorders, specifically oppositional disorders and/or attention deficit/hyperactivity disorder (ADHD), makes compliance with OCD treatment more difficult.

The large number of children and adolescents without treatment for OCD is a red flag to signal the urgent need for patient education. The methods to educate adults about OCD and other disorders may not be effective for young people. Novel methods to educate young people about OCD may include infomercials in the social media that are used by young people. Incorporation of characters with OCD who improve with treatment may be added to cartoons, video games, television shows, and other media used by young people. Incorporating children and adolescents with OCD in the team developing patient education for pediatric OCD would provide first-hand information about the activities accessed by young people.

Additionally patient education for pediatric OCD must include education of the adults who interact with children with OCD. Parents, teachers, pediatricians, and other adults must be alerted to look for evidence that a young person may have OCD. Children with obsessions may appear to be day-dreaming. Children with compulsions may take inordinate amounts of time to accomplish routine tasks. For example, a child with an obsession for dirt may take hours to wash hands and shower. The skin of the hands and other parts of the body may become red from the excessive washing.  Punishing a child for compulsions may be counterproductive. Instead emphasizing the existence of effective therapeutic interventions for OCD will point to a positive future. Assessment by pediatric mental health providers is key to establishing a diagnosis of pediatric OCD and developing an effective treatment plan.

A complete family history is essential, especially any history of relatives who may have obsessive-compulsive disorder (OCD) or Tourette syndrome (TS).

Adequate assessment of a child with potential OCD includes inquiry for a history of any infection that may have preceded the onset of symptoms. Accurate assessment is essential. Of structured interviews and psychological tests used, the Children's Yale–Brown Obsessive Compulsive Scale (CY-BOCS), which is a clinician-rated scale based on the Yale–Brown Obsessive-Compulsive Scale (Y-BOCS),[21, 22, 23] is considered the instrument of choice in making the definitive diagnosis.[24] The CY-BOCS is used for children younger than 18 years old and the Y-BOCS is for adults aged 18 years and older.[3]

Usual behavioral features

Sets of common obsessions and compulsions are observed in pediatric individuals with obsessive-compulsive disorder (OCD). Typically, these sets are described best as "just so" behaviors, in which certain things have to be arranged or performed in a particular way to relieve the anxiety. The most clinically useful and detailed symptoms checklist is included in the Y-BOCS.[3]

Common themes of obsessions include contamination, aggression, sex, the need for symmetry and order, harm to oneself or others, and the need to confess. These excessive thoughts result in the common compulsive behaviors of washing, repeating, checking, touching, counting, arranging, hoarding, or praying. The presence of hoarding symptoms is associated with an earlier age of onset and with the presence of attention-deficit/hyperactivity disorder and anxiety disorder.[25]

When overt, observable compulsive behaviors are relatively easy to observe to make the diagnosis (eg, washing, repeating, checking, touching); covert behaviors (eg, counting, praying, reading something again and again) are harder to assess and evaluate. If OCD is suspected and if a child is taking an extremely long time to complete some tasks, a high likelihood exists that the child may be engaged in one of these covert rituals.

Rage is a common behavior of youth with OCD. Severe rage attacks may seriously impair functioning in the family. Rage attacks may aggravate the functional impairment of obsessions and compulsions.[26]

Social functioning

Youth with OCD often demonstrate impaired peer relationships. They are fearful of negative evaluations. They exhibit victimization. They have fewer behaviors to facilitate social interactions with peers. They have fewer friends than peers. Also they want more friends than their peers. They have trouble making friends. Parents and teacher can facilitate optimal social functioning of young people with OCD.[27]

Parental accommodation

Parents themselves may experience anxiety associated with excessive hand washing and other severe compulsions and oppositional behaviors of the child. Parents may then alter their activities to accommodate the obsessions, compulsions, and the rage attacks of the child.[28, 26]

Physical examination of children with pediatric obsessive-compulsive disorder (OCD) may reveal the effects of compulsions. Repeated handwashing and showering may result in redness and irritation of the skin of the hands and other parts of the body.[2]

Children with obsessive-compulsive disorder (OCD) may develop other anxiety disorders, including panic disorder, social anxiety disorder, generalized anxiety disorder, and specific phobia; depressive or bipolar disorder. They may develop suicidal thoughts and self-destructive behaviors.[2] They may also develop attention-deficit/hyperactivity disorder or tics and Tourette syndrome (TS).[2]

The diagnostic criteria for obsessive-compulsive disorder (OCD) specify that a child or adolescent may have either obsessions or compulsions, although nearly all children with this disorder have both. The symptoms must cause some distress, consume more than 1 hour per day, or must significantly interfere with school, social activities, or important relationships.[2]

Although most adolescents and some children with OCD recognize the senselessness of the disorder, the requirement of insight into the disorder is not required for the diagnosis of OCD in children.

As with many neuropsychiatric disorders, a chronic waxing and waning of symptoms occurs in the chronic disorder of OCD. Thus, many families choose not to seek treatment, because the symptoms have decreased independent of treatment in the past.

Of structured interviews and psychological tests used in diagnosing OCD, the Children's Yale–Brown Obsessive-Compulsive Scale (CY-BOCS)[3]  is the criterion standard to make the definitive diagnosis. OCD is diagnosed according to DSM-IV-TR[29] if on the Y-BOCS a person scores 2, 3, or 4 on any of the following items: (1) time spent on obsessions, (2) interference from obsessions, (3) distress of obsessions, (6) time spent on compulsions, (7) interference from compulsions, or (8) distress of compulsions.[21]

Structural magnetic resonance imaging does not differentiate people with obsessive-compulsive disorder (OCD) from healthy controls.[30]

Among unmedicated people with OCD, activation in the right dorsal-lateral prefrontal cortex during a mental task with fMRI was postively correlated with total scores on Y-BOCS.[21]  These findings suggest a possible location for neuromodulation intervention.[31]

Resting-state functional connectivity magnetic resonance imaging (rs-fcMRI) demonstrate increased connectivity in the right auditory system (Brodman area 43) and decreased connectivity in the right Brodman area 8 and in Brodman area 40 in the cingulate system. These findings support the hypothesis of dysfunction of the cortico-striatal-thalamo-cortical system in OCD.[32]

Diffusion tensor imaging (DTI) studies has shown increased white matter connectivity potentially due to premature myelination in pediatric and adolescent patients with early-onset OCD.[33]

On proton magnetic resonance spectroscopy (1H-MRS) there are greater concentrations of choline and N-acetyl-aspartate in the right prefrontal white matter in children and adolescents with OCD.[34]  Also there has been a possible increase in Glx (combination of glutamate and glutamine) in the striatum in OCD.[35]  Furthermore, the levels of choline, myoinositol, and N-acetyl-aspartate in the right prefrontal white matter in children and adolescents with OCD are correlated with the severity of symptoms.[34]  

 

Evidence of an infection merits checking for group A beta-hemolytic streptococcal antigens to rule out pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). Streptococcal infections may be followed by the dramatic appearance of obsessive-compulsive disorder (OCD) and/or tics.[36]

Neuropsychological assessment by a pediatric neuropsychologist will help to establish the diagnoses of obsessive-compulsive disorder (OCD) and other disorders. Also a neuropsychologist who has performed a thorough neuropsychological evaluation can formulate an effective treatment plan. 

A comprehensive neuropsychological battery for people with possible OCD may include (1) executive function (Flanker Test),[37]  (2) cognitive set shifting[38] , (3) episodic memory,[39]  (4) working memory,[40]  (5) proxy for intelligence quotient (Picture Vocabulary), and (6) motor speed (Pegboard).[41]

 

Successful treatment of obsessive-compulsive disorder (OCD) involves the judicious use of SSRIs and structured psychotherapy designed to provide the patient with the skills to master the obsessive thoughts and accompanying compulsive behaviors. Both psychotherapy and pharmacotherapy are effective interventions for children with OCD.[42, 43] Management of infectious etiologies remains uncertain and may include strategies similar to those for Sydenham chorea.

Go to Pediatric Generalized Anxiety Disorder and Pediatric Panic Disorder for complete information on these topics.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder. Clinicians are advised to use SSRIs when indicated while watching the child closely for suicidal ideation and advising parents to carefully assess the child for suicidal thoughts, plans, and actions.

Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy (CBT) routinely is described as the psychotherapeutic treatment of choice for adults, children, and adolescents who have been diagnosed with obsessive-compulsive disorder (OCD). Unlike psychodynamic or insight-oriented psychotherapy, CBT helps the child to understand the disorder and develop strategies to identify problem situations and resist giving in to the obsessive thoughts and compulsive behaviors. Treatment relies heavily on exposing the individual to the problem situations and then preventing the compulsive response. The resulting anxiety then is managed by training children to use strategies that help them to work with their anxiety in a more effective and less disruptive way. Involvement of the family in the administration of CBT facilitates the consistent utilization and practice of the procedure.[44, 43, 45]

However, exposure to the anxiety-producing object is the key to success in treatment. Thus, for children who compulsively wash their hands because they feel that the hands are dirty or contaminated, the therapist may have them intentionally touch things that are dirty and then have patients wait several hours before washing their hands. This results in very high anxiety after the initial contamination, followed by a gradual reduction in anxiety over time, until hand washing is allowed some hours later. In pediatric patients, this exposure is presented gradually, under the patients' control, after patients have been taught other ways of managing their anxiety and fear.

Anxiety management techniques may include relaxation training, distraction, or imagery. Often, the OCD is personified as something that makes the child perform an action. Thus, children learn to assess situations and ask themselves if they really want to do something, as opposed to the perception that the OCD is making them do something. For school-aged children, the development of mastery and control is a critical issue in their overall psychologic growth; therefore, learning to overcome an irrational drive, such as one experienced with OCD, has a certain appeal to the children’s own sense of mastery.

With CBT, the initial goals are specific to 1 or 2 behaviors; however, as the patient becomes successful in coping with these situations, generalization usually occurs to other symptoms that have not been targeted. Usually, the patient reports an overall reduction in obsessive thoughts, general anxiety, and the need to perform certain actions.

While CBT requires a skilled therapist and 10–20 sessions to complete, its advantage is that once the skills are learned, the patient can use them in the future.

Therapists skilled in the administration of CBT may be located through the Anxiety Disorders Association of America, the Association for Behavioral and Cognitive Therapies, the Academy of Cognitive Therapy.

CBT and pharmacotherapy work well together clinically and exhibit the best results.[42, 46]  Participation in 14 sessions of CBT over 12 weeks in addition to treatment with serotonin reuptake inhibitors provided significantly greater improvement in patients with OCD aged 7–17 years than either (1) treatment with serotonin reuptake inhibitors alone or (2) treatment with serotonin reuptake inhibitors and instruction in CBT.[47]

Relaxation therapy

Relaxation therapy administered with the help of the family is also a promising technique for treatment of OCD.[44]

Exposure and response prevention therapy 

Exposure and response prevention therapy with extensive parental involvement demonstrates promise for preschool children with OCD as young as three years old.[48]

Psychodrama

Psychodrama in conjunction with sertraline has been reported to relieve treatment-resistant OCD.[24]

Eye movement desensitization and reprocessing (EMDR) 

A study demonstrated comprable completion rates and clinical outcomes.[49]

Treatment of OCD in adults has demonstrated that medications are effective, and the existing studies of children with obsessive-compulsive disorder (OCD) using medications also tend to suggest some benefit. SSRIs (ie, fluoxetine,[50, 51] fluvoxamine, paroxetine, citalopram, sertraline[52] ) have been demonstrated to be effective treatments for OCD, and they have a lower rate of adverse effects compared with previously used medications.[42] These SSRIs are considered the first-line medications for treatment of OCD. The adverse effect profile in children for these medicines is similar to that for adults, except that children and adolescents appear to be more prone to agitation if started at usual adult doses. 

Clomipramine, the second-line medication, is the most extensively studied medication in the pediatric population. Despite having more efficacy in reducing obsessive-compulsive symptoms in comparison with SSRIs,[42]  clomipramine results in a higher rate and severity of adverse effects in children.[42] These are the same as those observed in adults (eg, anticholinergic, antihistaminic, alpha blocking).[42]

No unexpected, long-term, adverse reactions have been observed with clomipramine; however, tachycardia and slightly increased PR-, QRS-, and QT-corrected intervals on electrocardiograms (ECGs) were noted. Given the potential for tricyclic antidepressant-related cardiotoxic effects, pretreatment and periodic ECG and therapeutic drug monitoring is warranted.

With all of these medicines, a large number of persons with OCD do not respond until after 8–12 weeks of treatment (dissimilar to the shorter time noted in the treatment of depression); thus, waiting at least 8 (preferably 10) weeks before changing medicines or dramatically raising dosages is important.

Approximately one third of patients do not respond to a particular SSRI, and the likelihood of responding drops significantly after 3 SSRI trials.

Because properly executed CBT can be a very effective treatment on its own, complex medication strategies are not recommended until the patient has a trial of CBT, along with an SSRI.

Class Summary

SSRIs are considered first-line agents. The tricyclic antidepressant clomipramine is also used, although it is often attended by more uncomfortable adverse effects.[42]

Fluoxetine (Prozac)

Fluoxetine is indicated for acute and maintenance treatment of obsessive-compulsive disorder (OCD) in children. It selectively inhibits presynaptic serotonin reuptake with minimal or no effect on the reuptake of norepinephrine or dopamine.

Fluoxetine may cause more gastrointestinal adverse effects than other SSRIs now currently available, which is the reason it is not recommended as a first choice. It may be given as a liquid and a capsule.

The drug may be administered in 1 dose or in divided doses. The presence of food does not appreciably alter levels of the medication. Fluoxetine may take up to 4-6 weeks to achieve steady state levels, as it has the longest half-life (72 h).

Its long half-life is an advantage and a drawback. If fluoxetine works well, an occasional missed dose is not a problem; if problems occur, eliminating all active metabolites takes a long time. The choice depends on adverse effects and drug interactions. Adverse effects of SSRIs seem to be quite idiosyncratic; thus, relatively few reasons exist to prefer one over another at this point if dosing is started at a conservative level and advanced as tolerated.

Fluvoxamine (Luvox CR)

Fluvoxamine is indicated for OCD in children aged 8-17 years. It enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer side effects than do tricyclic antidepressants.

Fluvoxamine has been shown to reduce repetitive thoughts, maladaptive behaviors, and aggression and to increase social relatedness and language use.

Sertraline (Zoloft)

Zoloft selectively inhibits presynaptic serotonin reuptake. It is indicated for OCD in children aged 6-17 years.

Paroxetine (Paxil, Pexeva)

This would be unlabeled use. Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake and has a weak effect on norepinephrine and dopamine neuronal reuptake. For maintenance dosing, make dosage adjustments to maintain the patient on the lowest effective dosage, and reassess the patient periodically to determine the need for continued treatment.

Citalopram (Celexa)

This would be unlabeled use. Citalopram enhances serotonin activity by selective reuptake inhibition at the neuronal membrane. SSRIs are the antidepressants of choice because of their minimal anticholinergic effects. All are equally efficacious. The choice depends on adverse effects and drug interactions.

Clomipramine (Anafranil)

Clomipramine is indicated for OCD in children aged 10-17 years. It is a dibenzazepine compound belonging to the family of tricyclic antidepressants. The drug inhibits the membrane pump mechanism responsible for the uptake of norepinephrine and serotonin in adrenergic and serotonergic neurons.

Clomipramine affects serotonin uptake while it affects norepinephrine uptake when converted into its metabolite, desmethylclomipramine. These actions may be responsible for its antidepressant activity. Clomipramine is overall more effective than SSRIs for children with OCD; however, clomipramine has more adverse effects.