- 1 Introduction
- 2 Epidemiology
- 3 Presentation
- 4 Diagnosis
- 5 Treatment trials
- 6 Black belt OCD
Evaluation and treatment of adult OCD is addressed in a separate article.
OCD in children and adolescents often goes unrecognized and undiagnosed due to its idiosyncratic, not always obvious nature.
- Point prevalence of pediatric OCD is 0.25% (British study 5-15 y.o., Heyman I, IntRevPsych 2003);
- Overall pediatric prevalence rate is 1-2% (USA studies, Apter A, JAACAP 1996)
- Incidence of OCD peaks during two developmental periods, pre-adolescents (mean 10 y.o.), and young adults (mean 20 y.o.). (Geller D, March J, Practice Parameter, JAACAP 2012)
- Childhood onset of OCD is more common in boys with a 3:2 ratio, (Lewis text p.550) while M:F ratio of OCD in adults is 1:1.
Genetic and non-genetic factors
- OCD has a significant familial/genetic component with higher concordance rates in monozygotic twins vs. dizygotic twins.
- Environmental triggers and immunological cross-reactions, particularly to Strep infection had been implicated.
- PANDAS - Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus, is attributed to immune response to Group A Strep, which can cause cross-reactivity and inflammation of basal ganglia. This can produce (the somewhat controversial) syndrome of PANDAS, which involves tics, OCD, and hyperactivity.
- Insistence on certain rituals and routines is common and normal in toddlers and pre-schoolers, as long as family functioning is not disrupted and a child can tolerate some disruption in the ritual (JACAAP parameter 2012)
- Severity of pediatric OCD may diminish and become sub-clinical with time.
- OCD is more likely to persist in youth with younger age of onset and longer duration of symptoms.
- Also more likely to persist are religious, hoarding, and sexual subtypes of OCD.
- Separation anxiety is a common comorbidity in children with OCD.
Children may have compulsions without obsessions.
- The most common obsessions in children and adolescents involve aggressive and catastrophic worries (e.g death of parent); these become less common in adults. (Geller DA, J Nerv Men D/o 2001)
- Sexual and religious obsessions are more common in adolescents.
- Contamination worries are common throughout the developmental spectrum.
- Most common compulsions across the developmental spectrum involve checking, cleaning, and ordering rituals.
- Hoarding compulsions are more common in children in adolescents and become less common in adults. (Geller DA, J Nerv Men D/o 2001)
- Children and adults need to have either obsessions or compulsions with marked distress, functional impairment (school, work, relationships) and taking >1hr/day.
- To be diagnosed with OCD, adults must recognize their O&C to be excessive or unreasonable, at least at some point during the disorder. This level of insight is not necessary for the diagnosis in children (DSM-IV)
Children's Yale-Brown Obsessive Compulsive Scale(CY-BOCS) is based on adult Y-BOCS, a clinician-administered instrument, that assesses degree of impairment and distress from obsessions and compulsions. Range of cumulative OCD severity:
- <7 - subclinical
- 8-15 - mild illness
- 16-23 - moderate illness
- 24-31 - severe
- 31-40 - extreme
- Pervasive developmental disorders involve stereotypies and rituals as the core criteria. OCD symtpoms are generally egodystonic and are accompanied by anxiety and fears.
- Tourette's and tic disorders have significant comorbidity with OCD, and it is often difficult to distinguish complex tics from compulsions.
A number of disorders have overlapping symptoms or behavioral manifestations with OCD; they have been termed obsessive-compulsive-related disorders (Hollander E, J Clin Psych 1996)
- preoccupation with bodily sensations or appearance: body dysmorphic disorder, anorexia nervosa, hypochondriasis.
- impulsive disorders: sexual compulsions, trichotillomania and self-injurious behaviors, pathological gambling, kleptomania.
- neurologic disorders: Tourette's and tics, torticollis, Sydenham's choreas, autism, PANDAS.
The Pediatric OCD Treatment Study (POTS) was a 12-week randomized controlled trial (JAMA, 2004).
- n=112 randomized to 4 groups (CBT alone, sertraline alone (SER), combination (COMB), and placebo);
- Remission rates were statistically similar for CBT and COMB groups (bit clinically different 39% and 53%).
- COMB group was superior to SER (21% remission rate) and placebo (3.6%).
Geller DA, et.al. Which SSRI? A Meta-Analysis of Pharmacotherapy Trials in Pediatric Obsessive-Compulsive Disorder (AM J Psych 2003)
- pooled RCTs involving four SSRIs (paroxetine, fluoxetine, fluvoxamine, and sertraline) and SRI clomipramine vs. placebo, total n = 1044. It found statistically significant but modest effect size of 0.46
- mean difference from the placebo: clomipramine > paroxetine = fluoxetine = sertraline = fluvoxamine > placebo
- due to adverse effects of clomipramine, it should not be the first line treatment.
- usually used after two failed SSRI trials
- should be considered before second generation antipsychotics.
AACAP Practice Parameter
AACAP guidelines were updated in 2012 (JACAAP 51(1) 2012); recommendations were categorized by strength/amount of evidence as Clinical standard (CS) > Clinical Guideline (CG) > Opinion (O) > not endorsed (NE)
- youth should be routinely screened for OC symtpoms (CG);
- those with suspected OC symtpoms should be further evaluated using DSM-IV and CY-BOCS (CS), and have a full psychiatric, medical, developmental, and school evaluations (CG)
- CBT is first-line treatment in mild to moderate OCD (CS) (meta-analysis (Watson HJ 2008 found large effect size: 1.45; >50% remission verify)
- For moderate to severe OCD (CY-BOCS>23), a combination treatment of SRI medications (SSRIs, clomipramine) and CBT is indicated (CS)
- Treatment should continue for 6-12 months after stabilization before a gradual taper is attempted. Children who relapse may require longer treatment.
- Side effects of SRIs, particularly conversion to mania, suicidality, and cardiovascular effects of clomipramine should be carefully weighted.
- Medication augmentation may be appropriate in treatment resistant cases (failed 2 SRIs trials x10 weeks each at max/tolerated dose x3weeks). (OP)
After failure of >3 SSRIs at therapeutic doses, the following can be helpful (AACAP workshop 2016)
- augmentation with second-generation antipsychotic; this is particularly effective in youth with tics or schizotypal features.
- using supre-therapeutc doses of SSRIs
- augmentation with clomipramine
Black belt OCD
- Youth with strong family history of OCD are less likely to respond to CBT alone; they are good candidates for combined treatment (Garcia JAACAP 2010)
- common commorbidites (tics, ADHD, ODD) are associated with lower response rates and higher relapse when OCD is treated with an SSRI; CBT improves these outcomes. (March J Biol Psych 2007)