Approach Considerations

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]

Imaging Studies

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]

Laboratory Studies

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]

Other Tests

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]

Treatment & Management

Huyser C, Veltman DJ, de Haan E, Boer F. Paediatric obsessive-compulsive disorder, a neurodevelopmental disorder? Evidence from neuroimaging. Neurosci Biobehav Rev. 2009 Jun. 33(6):818-30. [QxMD MEDLINE Link].
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013. 235-242.
Scahill L, Riddle MA, McSwiggin-Hardin M, Ort SI, King RA, Goodman WK, et al. Children's Yale-Brown Obsessive Compulsive Scale: reliability and validity. J Am Acad Child Adolesc Psychiatry. 1997 Jun. 36 (6):844-52. [QxMD MEDLINE Link].
Nielsen M, Kapitány R, Elkins R. The perpetuation of ritualistic actions as revealed by young children's transmission of normative behavior. Evolution and Human Behavior. 2015. 36:191-198. [Full Text].
Fernández de la Cruz L, Rydell M, Runeson B, D'Onofrio BM, Brander G, Rück C, et al. Suicide in obsessive-compulsive disorder: a population-based study of 36 788 Swedish patients. Mol Psychiatry. 2017 Nov. 22 (11):1626-1632. [QxMD MEDLINE Link].
Kalra SK, Swedo SE. Children with obsessive-compulsive disorder: are they just "little adults"?. J Clin Invest. 2009 Apr. 119(4):737-46. [QxMD MEDLINE Link]. [Full Text].
Davis LK, Yu D, Keenan CL, Gamazon ER, Konkashbaev AI, Derks EM, et al. Partitioning the heritability of Tourette syndrome and obsessive compulsive disorder reveals differences in genetic architecture. PLoS Genet. 2013 Oct. 9(10):e1003864. [QxMD MEDLINE Link]. [Full Text].
Carlsson ML. On the role of cortical glutamate in obsessive-compulsive disorder and attention-deficit hyperactivity disorder, two phenomenologically antithetical conditions. Acta Psychiatr Scand. 2000 Dec. 102(6):401-13. [QxMD MEDLINE Link].
Carlsson ML. On the role of prefrontal cortex glutamate for the antithetical phenomenology of obsessive compulsive disorder and attention deficit hyperactivity disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2001 Jan. 25(1):5-26. [QxMD MEDLINE Link].
Kariuki-Nyuthe C, Gomez-Mancilla B, Stein DJ. Obsessive compulsive disorder and the glutamatergic system. Curr Opin Psychiatry. 2014 Jan. 27 (1):32-7. [QxMD MEDLINE Link].
Thorsen AL, Hagland P, Radua J, Mataix-Cols D, Kvale G, Hansen B, et al. Emotional Processing in Obsessive-Compulsive Disorder: A Systematic Review and Meta-analysis of 25 Functional Neuroimaging Studies. Biol Psychiatry Cogn Neurosci Neuroimaging. 2018 Jun. 3 (6):563-571. [QxMD MEDLINE Link].
Pearlman DM, Vora HS, Marquis BG, Najjar S, Dudley LA. Anti-basal ganglia antibodies in primary obsessive-compulsive disorder: systematic review and meta-analysis. Br J Psychiatry. 2014 Jul. 205 (1):8-16. [QxMD MEDLINE Link].
Ebrahimi Taj F, Noorbakhsh S, Ghavidel Darestani S, Shirazi E, Javadinia S. Group A β-hemolytic Streptococcal Infection in Children and the Resultant Neuro-psychiatric Disorder; a Cross Sectional Study; Tehran, Iran. Basic Clin Neurosci. 2015 Jan. 6 (1):38-43. [QxMD MEDLINE Link].
Abali O, Nazik H, Gurkan K, Unuvar E, Sidal M, Ongen B, et al. Group A beta hemolytic streptococcal infections and obsessive-compulsive symptoms in a Turkish pediatric population. Psychiatry Clin Neurosci. 2006 Feb. 60 (1):103-5. [QxMD MEDLINE Link].
Helbing ML, Ficca M. Obsessive-compulsive disorder in school-age children. J Sch Nurs. 2009 Feb. 25(1):15-26. [QxMD MEDLINE Link].
Grover S, Sarkar S, Gupta G, Kate N, Ghosh A, Chakrabarti S, et al. Factor analysis of symptom profile in early onset and late onset OCD. Psychiatry Res. 2018 Apr. 262:631-635. [QxMD MEDLINE Link]. [Full Text].
Stewart SE, Platko J, Fagerness J, Birns J, Jenike E, Smoller JW, et al. A genetic family-based association study of OLIG2 in obsessive-compulsive disorder. Arch Gen Psychiatry. 2007 Feb. 64 (2):209-14. [QxMD MEDLINE Link].
[Guideline] Mayo Clinic. Obsessive-compulsive disorder (OCD). Mayo Foundation for Medical Education and Research. Available at https://www.mayoclinic.org/diseases-conditions/obsessive-compulsive-disorder/symptoms-causes/syc-20354432. 2021; Accessed: 9 Dec 2021.
Stewart SE, Geller DA, Jenike M, Pauls D, Shaw D, Mullin B, et al. Long-term outcome of pediatric obsessive-compulsive disorder: a meta-analysis and qualitative review of the literature. Acta Psychiatr Scand. 2004 Jul. 110(1):4-13. [QxMD MEDLINE Link].
Atmaca M, Onalan E, Yildirim H, Yuce H, Koc M, Korkmaz S. The association of myelin oligodendrocyte glycoprotein gene and white matter volume in obsessive-compulsive disorder. J Affect Disord. 2010 Aug. 124 (3):309-13. [QxMD MEDLINE Link].
Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989 Nov. 46(11):1006-11. [QxMD MEDLINE Link].
Castro-Rodrigues P, Camacho M, Almeida S, Marinho M, Soares C, Barahona-Corrêa JB, et al. Criterion Validity of the Yale-Brown Obsessive-Compulsive Scale Second Edition for Diagnosis of Obsessive-Compulsive Disorder in Adults. Front Psychiatry. 2018. 9:431. [QxMD MEDLINE Link].
Storch EA, Rasmussen SA, Price LH, Larson MJ, Murphy TK, Goodman WK. Development and psychometric evaluation of the Yale-Brown Obsessive-Compulsive Scale--Second Edition. Psychol Assess. 2010 Jun. 22 (2):223-32. [QxMD MEDLINE Link].
Cohen D, Delaroche P, Flament MF, Mazet P. Cas clinique : psychodrame individuel comme abord thérapeutique d’un trouble obsessionnel compulsif resistant [Case report: Individual psychodrama for treatment resistant obsessive-compulsive disorder]. Neuropsychiatrie de l'enfance et de l'adolescence. 2014. 62:19-21.
Frank H, Stewart E, Walther M, Benito K, Freeman J, Conelea C, et al. Hoarding behavior among young children with obsessive-compulsive disorder. J Obsessive Compuls Relat Disord. 2014 Jan 1. 3(1):6-11. [QxMD MEDLINE Link]. [Full Text].
Storch EA, Jones AM, Lack CW, Ale CM, Sulkowski ML, Lewin AB, et al. Rage attacks in pediatric obsessive-compulsive disorder: phenomenology and clinical correlates. J Am Acad Child Adolesc Psychiatry. 2012 Jun. 51(6):582-92. [QxMD MEDLINE Link].
[Guideline] Borda T, Feinstein BA, Neziroglu F, Veccia T,Perez-Rivera R. Are children with obsessive–compulsive disorder at risk for problematic peer relationships?. Journal ofObsessive-CompulsiveandRelatedDisorders. 2013. 2:359-365. [Full Text].
Flessner CA, Freeman JB, Sapyta J, et al. Predictors of parental accommodation in pediatric obsessive-compulsive disorder: findings from the Pediatric Obsessive-Compulsive Disorder Treatment Study (POTS) trial. J Am Acad Child Adolesc Psychiatry. 2011 Jul. 50(7):716-25. [QxMD MEDLINE Link]. [Full Text].
American Psychiatric Association. Diagnostic and Statistical Manuel of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association; 2000.
Bruin WB, Taylor L, Thomas RM, Shock JP, Zhutovsky P, Abe Y, et al. Structural neuroimaging biomarkers for obsessive-compulsive disorder in the ENIGMA-OCD consortium: medication matters. Transl Psychiatry. 2020 Oct 8. 10 (1):342. [QxMD MEDLINE Link].
Oh S, Jung WH, Kim T, Shim G, Kwon JS. Brain Activation of Patients With Obsessive-Compulsive Disorder During a Mental Rotation Task: A Functional MRI Study. Front Psychiatry. 2021. 12:659121. [QxMD MEDLINE Link].
Weber AM, Soreni N, Noseworthy MD. A preliminary study of functional connectivity of medication naïve children with obsessive-compulsive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2014 Aug 4. 53:129-36. [QxMD MEDLINE Link].
Koch K, Reess TJ, Rus OG, Zimmer C, Zaudig M. Diffusion tensor imaging (DTI) studies in patients with obsessive-compulsive disorder (OCD): a review. J Psychiatr Res. 2014 Jul. 54:26-35. [QxMD MEDLINE Link].
Weber AM, Soreni N, Stanley JA, Greco A, Mendlowitz S, Szatmari P, et al. Proton magnetic resonance spectroscopy of prefrontal white matter in psychotropic naïve children and adolescents with obsessive-compulsive disorder. Psychiatry Res. 2014 Apr 30. 222(1-2):67-74. [QxMD MEDLINE Link].
Naaijen J, Lythgoe DJ, Amiri H, Buitelaar JK, Glennon JC. Fronto-striatal glutamatergic compounds in compulsive and impulsive syndromes: a review of magnetic resonance spectroscopy studies. Neurosci Biobehav Rev. 2015 May. 52:74-88. [QxMD MEDLINE Link].
[Guideline] National Institute of Mental Health. PANDAS—Questions and Answers. www.nimh.nih.gov. Available at https://www.nimh.nih.gov/health/publications/pandas. 2019; Accessed: 9 Dec 2021.
Hanna GL, Carrasco M, Harbin SM, Nienhuis JK, LaRosa CE, Chen P, et al. Error-related negativity and tic history in pediatric obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry. 2012 Sep. 51 (9):902-10. [QxMD MEDLINE Link].
Zelazo PD. The Dimensional Change Card Sort (DCCS): a method of assessing executive function in children. Nat Protoc. 2006. 1 (1):297-301. [QxMD MEDLINE Link].
Dikmen SS, Bauer PJ, Weintraub S, Mungas D, Slotkin J, Beaumont JL, et al. Measuring episodic memory across the lifespan: NIH Toolbox Picture Sequence Memory Test. J Int Neuropsychol Soc. 2014 Jul. 20 (6):611-9. [QxMD MEDLINE Link].
Tulsky DS, Carlozzi N, Chiaravalloti ND, Beaumont JL, Kisala PA, Mungas D, et al. NIH Toolbox Cognition Battery (NIHTB-CB): list sorting test to measure working memory. J Int Neuropsychol Soc. 2014 Jul. 20 (6):599-610. [QxMD MEDLINE Link].
Akshoomoff N, Newman E, Thompson WK, McCabe C, Bloss CS, Chang L, et al. The NIH Toolbox Cognition Battery: results from a large normative developmental sample (PING). Neuropsychology. 2014 Jan. 28 (1):1-10. [QxMD MEDLINE Link]. [Full Text].
Sánchez-Meca J, Rosa-Alcázar AI, Iniesta-Sepúlveda M, Rosa-Alcázar A. Differential efficacy of cognitive-behavioral therapy and pharmacological treatments for pediatric obsessive-compulsive disorder: a meta-analysis. J Anxiety Disord. 2014 Jan. 28(1):31-44. [QxMD MEDLINE Link].
Torp NC, Dahl K, Skarphedinsson G, Thomsen PH, Valderhaug R, Weidle B, et al. Effectiveness of cognitive behavior treatment for pediatric obsessive-compulsive disorder: acute outcomes from the Nordic Long-term OCD Treatment Study (NordLOTS). Behav Res Ther. 2015 Jan. 64:15-23. [QxMD MEDLINE Link].
Freeman J, Garcia A, Benito K, Conelea C, Sapyta J, Khanna M, et al. The Pediatric Obsessive Compulsive Disorder Treatment Study for Young Children (POTS jr): Developmental Considerations in the Rationale, Design, and Methods. J Obsessive Compuls Relat Disord. 2012 Oct. 1(4):294-300. [QxMD MEDLINE Link]. [Full Text].
Freeman J, Garcia A, Frank H, Benito K, Conelea C, Walther M, et al. Evidence base update for psychosocial treatments for pediatric obsessive-compulsive disorder. J Clin Child Adolesc Psychol. 2014. 43 (1):7-26. [QxMD MEDLINE Link].
Öst LG, Riise EN, Wergeland GJ, Hansen B, Kvale G. Cognitive behavioral and pharmacological treatments of OCD in children: A systematic review and meta-analysis. J Anxiety Disord. 2016 Oct. 43:58-69. [QxMD MEDLINE Link].
Franklin ME, Sapyta J, Freeman JB, et al. Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the Pediatric OCD Treatment Study II (POTS II) randomized controlled trial. JAMA. 2011 Sep 21. 306(11):1224-32. [QxMD MEDLINE Link].
Lewin AB, Park JM, Jones AM, Crawford EA, De Nadai AS, Menzel J, et al. Family-based exposure and response prevention therapy for preschool-aged children with obsessive-compulsive disorder: a pilot randomized controlled trial. Behav Res Ther. 2014 May. 56:30-8. [QxMD MEDLINE Link].
Marsden Z, Lovell K, Blore D, Ali S, Delgadillo J. A randomized controlled trial comparing EMDR and CBT for obsessive-compulsive disorder. Clin Psychol Psychother. 2018 Jan. 25 (1):e10-e18. [QxMD MEDLINE Link].
Rossi A, Barraco A, Donda P. Fluoxetine: a review on evidence based medicine. Ann Gen Hosp Psychiatry. 2004 Feb 12. 3(1):2. [QxMD MEDLINE Link]. [Full Text].
Alaghband-Rad J, Hakimshooshtary M. A randomized controlled clinical trial of citalopram versus fluoxetine in children and adolescents with obsessive-compulsive disorder (OCD). Eur Child Adolesc Psychiatry. 2009 Mar. 18(3):131-5. [QxMD MEDLINE Link].
Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA. 2004 Oct 27. 292(16):1969-76. [QxMD MEDLINE Link].
Marsh R, Maia TV, Peterson BS. Functional disturbances within frontostriatal circuits across multiple childhood psychopathologies. Am J Psychiatry. 2009 Jun. 166(6):664-74. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

of 0

Author

James Robert Brasic, MD, MPH, MS, MA Assistant Professor, Russell H Morgan Department of Radiology and Radiological Science and Neurology, Division of Nuclear Medicine and Molecular Imaging, Assistant Professor, Department of Neurology, Johns Hopkins University School of Medicine

James Robert Brasic, MD, MPH, MS, MA is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, International Parkinson and Movement Disorder Society, Society for Neuroscience, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Johns Hopkins University School of Medicine<br/>Serve(d) as a speaker or a member of a speakers bureau for: Society of Nuclear Medicine and Molecular Imaging, Maryland Regional Council of Child and Adolescent Psychiatry<br/>Received research grant from: National Institutes of Health, Johns Hopkins University School of Medicine, Intellectual & Developmental Disabilities Research Center (U54 HD079123) at the Kennedy Krieger Institute<br/>Received income in an amount equal to or greater than $250 from: Gerson Lehrman Group; Guidepost<br/>Received royalty from Medscape for other.

Coauthor(s)

Ashley B Durbin, BS, BA

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Farzaneh Farhadi, MD

Disclosure: Nothing to disclose.

Acknowledgements

This research is supported by the Essel Foundation, the Brain and Behavior Research Foundation (NARSAD), the Tourette Syndrome Association Inc, and the National Institutes of Health.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author W Douglas Tynan, PhD, to the development and writing of the source article.

Sections Pediatric Obsessive-Compulsive Disorder
Overview
Presentation
DDx
Workup
Treatment
Medication
References

Pediatric Obsessive-Compulsive Disorder Workup

Approach Considerations

Imaging Studies

Laboratory Studies

Other Tests

References

Tables

Contributor Information and Disclosures

What would you like to print?