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

Studies suggest that there is a familial component (1). The gene networks of OCD are highly complex and include those involved in synaptic transmission, neurodevelopment, and immune and inflammatory systems (2). Neuroimaging studies point to a possible issue with the cortico-striatal-thalamic circuits (3).

There is evidence that some cases with acute (overnight) onset have been associated with infection (4, 5). 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 (6–8).

Research in this area is ongoing and controversial, and if PANDAS or PANS is suspected, consultation with a specialist in these disorders is recommended.

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?”

• Psychiatric assessment

• Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria

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.

A diagnosis of OCD requires that the obsessions and compulsions 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).

• 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 medications and are generally well tolerated (see table Medications 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 (4–678(9, 10)

(11) may be more effective and have a better response rate than SSRIs in children but not adults (12

Transcranial magnetic stimulation is 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.

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.