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AnitaPuustjärvi

Obsessive-Compulsive Disorder (Ocd) in Children

Essentials

  • Transient obsessive thoughts, ritualistic behavior and magical thinking occur in children often in the preschool years and during prepuberty.
  • Ritualistic behavior as part of normal development does not impair functional capacity and is not associated with significant anxiety.
  • In obsessive-compulsive disorder (OCD), the symptoms increasingly take time away from age-appropriate activities, cause stress and interfere with functional capacity.
  • Treatment of OCD is indicated when the symptoms have a significantly negative impact on the child him/herself and/or on those close to the child.
  • Treatment consists of cognitive behavioral therapy either alone or combined with SSRI medication, as necessary.

Epidemiology

  • The prevalence is about 1-3% in all age groups.
  • The symptoms most often start at the age of 9-14, but they may appear already before school age.
  • In younger age groups the disorder is more common in boys, but towards adolescence there is no longer a difference between the sexes.
  • About 30-50% of adult OCD cases have already begun in childhood.
    • Up to 80% of adults with OCD estimate that their symptoms already started before the age of 18 years.
    • Associated/parallel diagnoses are common.

Aetiology

  • OCD is considered to have a multifactorial background. Hereditary and neurobiological factors appear to have a central role in the aetiology of the condition but experiences and environmental factors may trigger symptoms and modify the clinical picture.
    • OCD is polygenic, and it appears to be explained by genetic factors slightly more often in children (45-58%) than in adults (30-40%).
    • There is shared genetic susceptibility to OCD and several neuropsychiatric disorders (Tourette's syndrome, ADHD, autism spectrum disorders).
  • The family and its functionality are not associated with specific pathologies more than average but the disorder often increases conflicts and negative interaction between family members. The family often becomes enmeshed in the child's symptoms in a way that intensifies the symptoms.
    • Family members may try to help the child with the ritualistic and avoidance behaviors, which may temporarily alleviate the child's anxiety.
    • When helping with the compulsive rituals, however, the family members unintentionally reinforce the child's irrational fears and anxiety, which increases obsessive-compulsive symptoms.
    • Limiting the child's obsessive-compulsive symptoms and tolerating the anxiety it causes may be difficult and give rise to conflicts between family members, which may further aggravate the child's symptoms.
  • The neurobiological aetiology appears to be associated with neural networks in the brain.
  • Sometimes obsessive-compulsive symptoms and tic symptoms may start suddenly and severly after an infection caused by streptococci, mycoplasma or other agents (PANDAS = paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections; PANS = paediatric acute-onset neuropsychiatric syndrome), but the significance and aetiology of this phenomenon are still unclear.
    • The symptomatology may include other neurological symptoms such as choreiform movements, balance difficulties and motoric hyperactivity. Eating problems are also possible.
    • Careful and systematic differential diagnosis and adequate treatment of a confirmed infection are important.
    • Ordinary treatment of OCD is also effective against symptoms triggered by infections.
    • There is not enough evidence on the efficacy and safety of immunotherapies or other possible therapies. A treatment trial using such therapies generally requires a joint decision by several specialties and careful monitoring of symptoms.

Symptoms and clinical picture

  • Obsessive-compulsive disorder manifests as recurrent obsessive thoughts or compulsive behaviours, or both. They require unreasonable amounts of time, cause considerable suffering and anguish or significant inability to cope in everyday life, e.g. in school, working life or social relationships.
    • Obsessions are unpleasant and involuntary thoughts, mental images or impulses that feel strange and invade one's mind.
    • Compulsions are time-consuming acts performed according to a specific scheme or rule. They aim, one way or another, at reducing the anxiety associated with obsessions or at preventing an act or event that is perceived harmful.
  • In children, compulsions are more common than obsessions. As the child approaches adolescence, the symptom picture becomes similar to that of adults.
  • The most common obsessions in children are associated with the fear of becoming dirty or contaminated, aggression, damage inflicted to oneself or others, compulsive need for symmetry and precision, or with worrying about the appropriateness of one's own bodily functions.
  • Typical compulsions in children include washing and cleaning, ensuring and organizing.. A compulsion may also involve repeating a movement or act until it "is done correctly".
    • Routines associated with getting up in the morning or going to bed at night or moving from one place to another that increase the feeling of safety in small children are not obsessive-compulsive symptoms. Continuous asking or repeating the same thing are also common and related to the developmental phase of preschool-age children, for instance.
  • Fluctuation is typical for obsessive-compulsive symptoms, as is also variation in their intensity and amount. Symptoms may also change or turn into something else.
    • The symptoms may include compulsive, rigid rules, such as washing hands exactly ten times. The compulsive need to follow the rule may be more essential symptom than the content of the act.
    • Preventing the child from performing compulsive acts increases the child's anxiety and may also trigger a temper outburst.
  • The ability to recognize the symptoms varies depending on the child's age and developmental stage. The child does not always perceive the symptoms him/herself as hindering, even if they would clearly affect the functional capacity. The child may regard the symptoms as belonging to his/her persona and he/she may try to conceal them.
    • If recognition of symptoms is poor, the motivation and commitment to treatment may remain weak. Poor self-assessment ability may be associated with concomitant autistic spectrum disorder Autism Spectrum Disorder.

Diagnosis and differential diagnosis

  • Assessment and treatment of OCD is indicated when the symptoms have a negative impact on the child him/herself and possibly also on those close to the child or when the symptoms affect the child's functional capacity. The assessment can be done at a child health clinic, in school health care or primary health care, consulting specialized care, as necessary.
  • Age and developmental stage and phenomena typical for these should be considered when assessing symptoms in children and adolescents. Children may try to conceal their symptoms, which may make it more difficult to recognize such symptoms.
  • Extensive and systematic investigation of functional capacity, including family history and family situation, is needed to assess the symptoms.
    • Symptoms and functional capacity at home, in early childhood education and care / school/studies and hobbies
    • Duration of symptoms and changes to them
    • Effect of circumstances and the environment on symptoms
    • Somatic and neurological status and any recent symptoms of infection
    • Other disorders and their medication
  • Assessment of symptoms may be carried out using questionnaires, such as the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). The OCI-R, an obsessional compulsive inventory for adults can possibly also be used as far as applicable to assess symptoms http://novopsych.com/assessments/diagnosis/obsessional-compulsive-inventory-revised-oci-r/. Responses should be considered in relation to other data on the child's functional capacity.
  • In differential diagnosis, neurodevelopmental disorders, such as tic symptoms Tic Disorders in Childhood, ADHD ADHD and autism spectrum disorder Autism Spectrum Disorder, and other anxiety disorders, depression Childhood Depression and posttraumatic disorders should be considered. Other affective and psychotic disorders are also possible.
  • Concomitant disorders occur in 60-80% of patients. Of these, neurodevelopmental disorders, long-standing tics Tic Disorders in Childhood and Tourette's syndrome, ADHD ADHD, autism spectrum disorder Autism Spectrum Disorder, various fears, depression Childhood Depression and conduct disorder Conduct Disorders in Children and Adolescents are the most common. Other anxiety disorders, affective and psychotic disorders are also possible.
    • The symptoms of ADHD and its medication may provoke or intensify the symptoms; inattention, for instance, may increase the need to keep checking and to follow routines.
    • It is important to recognize developmental disorders and learning difficulties.

Treatment

  • When obsessive-compulsive symptoms are detected in a child or an adolescent, patient guidance regarding the disorder and various treatment alternatives should be given to the patient him/herself and his/her parents.
    • Check local sources for applicable online resources.
  • Treatment can be started in primary health care, such as a unit offering primary level mental health services for children and adolescents. If the symptoms are severe or if there are demanding differential diagnostic problems, or if treatment at primary care level does not produce a response, the child or adolescent should be referred to specialized care.
  • Current psychosocial stress factors should be reduced. Different methods for anxiety and stress management may be useful.
  • Supportive measures in early childhood education and in school can be used to support the child's other treatment.
  • Cognitive behavioural therapy reduces obsessive-compulsive symptoms in children and adolescents http://pubmed.ncbi.nlm.nih.gov/31589909/ http://pubmed.ncbi.nlm.nih.gov/33186776/ http://pubmed.ncbi.nlm.nih.gov/33618297/. It may be provided as individual or group therapy.
    • The exposure and response prevention (ERP) method is most often applied in therapy.
  • Pharmacotherapy may be combined with psychosocial treatments if these alone do not alleviate the symptoms sufficiently. In children, pharmacotherapy should be started in specialized care or in consultation with a specialist physician. In adolescents, pharmacotherapy can be provided in primary health care according to the same principles as in adults.
  • The primary drugs are the SSRIs sertraline http://pubmed.ncbi.nlm.nih.gov/31447707/ http://pubmed.ncbi.nlm.nih.gov/25769521/, fluoxetine http://pubmed.ncbi.nlm.nih.gov/32242450/ http://pubmed.ncbi.nlm.nih.gov/31447707/ http://pubmed.ncbi.nlm.nih.gov/30025255/, fluvoxamine http://pubmed.ncbi.nlm.nih.gov/31447707/ http://pubmed.ncbi.nlm.nih.gov/25769521/ http://pubmed.ncbi.nlm.nih.gov/14594734/ and paroxetinehttp://pubmed.ncbi.nlm.nih.gov/31447707/http://pubmed.ncbi.nlm.nih.gov/25769521/http://pubmed.ncbi.nlm.nih.gov/14594734/. There is insufficient research data on citalopram to assess its efficacy in the treatment of obsessive-compulsive disorder in children and adolescents.
    • In severe symptoms, drug combinations shown to be effective in adults, such as SSRIs combined with antipsychotics can be used in specialized care, as considered appropriate.
  • Need for pharmacotherapy is increased by concomitant disorders, such as severe depression, other anxiety disorders or psychotic symptoms, as well as OCD in a close relative.
    • Clinical response to pharmacotherapy and alleviation of symptoms may take as long as 6-10 weeks after starting the drug.
    • Pharmacetherapy is usually continued for several months after the alleviation of symptoms.
    • Assessment of the need for pharmacotherapy requires expertise in the treatment of children's OCD.
  • Participation in the treatment by parents and other adults close to the child is necessary.
    • Parents act as the child's coaches and reinforce his/her commitment to the therapy. The parents should also be supported in limiting the obsessive-compulsive symptoms, for example to limit the number of compulsive acts and to bear the resulting own and child's anxiety.
    • If a parent has anxiety or obsessive-compulsive symptoms too, their treatment is important for a successful treatment of the child. Joint visits or family therapy may also be required.
    • Pedagogical supportive measures and arrangements may be required in early childhood education and in school.
  • The course of the disorder is variable. Relapses of symptoms are common.

    References

    • [Obsessive-compulsive disorder]. A Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim, the Finnish Psychiatric Association and the Finnish Society for Child and Adolescent Psychiatry. Helsinki: the Finnish Medical Society Duodecim, 2023 (accessed 14 August 2024). Available in Finnish at http://www.kaypahoito.fi/hoi50129.
    • Geller DA, Homayoun S, Johnson G. Developmental Considerations in Obsessive Compulsive Disorder: Comparing Pediatric and Adult-Onset Cases. Front Psychiatry 2021;12():678538 [PubMed]
    • Nazeer A, Latif F, Mondal A, et al. Obsessive-compulsive disorder in children and adolescents: epidemiology, diagnosis and management. Transl Pediatr 2020;9(Suppl 1):S76-S93 [PubMed]
    • Sigra S, Hesselmark E, Bejerot S. Treatment of PANDAS and PANS: a systematic review. Neurosci Biobehav Rev 2018;86():51-65 [PubMed]
    • American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 2012;51(1):98-113. [PubMed]