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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 take increasingly time away from things appropriate for age, 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 the child's close persons.
- Treatment consists of cognitive behavioral therapy either alone or sometimes connected to SSRI medication.
Epidemiology
- The prevalence among children and adolescents has been found to be between 1% and 3% depending on the sample and age group studied.
- 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 more 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 started already before the age of 18 years.
- The obsessive-compulsive disorder has a tendency to become chronic and is often associated with depression.
- Early onset, female sex, severe symptoms, long-term symptoms and other associated disturbances are predictive of the persistence of an individual's OCD.
- The delay in seeking psychiatric evaluation and care has been estimated to be long which might impact the prognosis. Early intervening is recommended.
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.
- The disorder is often associated with tic disorders and both of these disorders are more common in members of the immediate family than in the population in general.
- The role of environmental factors is unclear, but stress and stressful situations may trigger the disorder or worsen already existing symptoms.
- The family and its functionality are not associated with specific pathologies more than average. Nevertheless, the family often becomes enmeshed in the child's symptoms.
- Family members may try to help the child in the ritualistic and avoidance behaviors, which may temporarily alleviate the child's anxiety.
- When helping in 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 dysfunction of the fronto-temporal lobes, basal ganglia and thalamus, as well as with imbalance in the functioning of the networks of neural pathways connecting these areas of the brain.
- Of the neurotransmitters, especially serotonin but also dopamine and glutamate function abnormally.
- 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 symptom picture may contain other neurological symptoms, such as choreiform movements, balance difficulties and motoric hyperactivity. Also eating problems are possible.
- Careful and systematic differential diagnosis and adequate treatment of a confirmed infection are important.
- There is not enough evidence on the effectiveness and safety of immunotherapies and 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.
- 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 continuous washing of the hands or other washing, ensuring, repetition of acts, compulsive touching and organizing. A compulsion may also involve repeating a movement or act until it "is done correctly".
- Various compulsive ritualistic behaviors associated with going to bed, rising up, dressing and going to school as well as continuous asking or repeating the same thing are common in children in certain age phases.
- The symptoms are often perceived as unpleasant and as being against common sense. In the beginning one usually tries actively to resist them, but later the resistance decreases.
- Fluctuation of symptoms is common, as is also variation in their strength 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 Disorders.
- Assessment of symptoms may be carried out using questionnaires, such as the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS, available e.g. at http://iocdf.org/professionals/training-institute/btti/general-attendee-info/assessments-worksheets/).
- Impairments in executive, memory and visuospatial functioning have been identified in affected individuals.
- Childhood onset OCD is very often associated with other psychiatric disorders, such as long-standing tics Tic Disorders in Childhood, especially Tourette's syndrome, autistic spectrum disorderAutism Spectrum Disorders, severe depression Childhood Depression, anxiety disorder, ADHD ADHD and conduct disorder Conduct Disorders in Children and Adolescents.
Treatment
- Treatment should include sufficient psychoeducation for the child, family and close environment about the disorder and its treatment options.
- Current psychosocial stress factors should be reduced. Different methods for anxiety and stress management may be useful.
- Evidence-based treatment consists of cognitive behavioral therapy (CBT) Behavioural and Cognitive Behavioural Therapy for Obsessive Compulsive Disorder in Children and Adolescents alone or, in severe symptoms, combined with SSRI drugs that affect serotonin metabolismPharmacotherapy for Anxiety Disorders in Children and Adolescents.
- 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.
- Treatment of OCD typically requires higher drug doses than other mood disorders.
- In severe symptoms, SSRI medications may be combined with an antipsychotic 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 of parents and other close adults in the treatment is necessary.
- Parents act as the child's coaches and reinforce his/her commitment to the therapy. The parents are also 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 also a parent has anxiety or obsessive-compulsive symptoms, their treatment is important for a successful treatment of the child. Also joint visits or family therapy may 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
- 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]
- Sigra S, Hesselmark E, Bejerot S. Treatment of PANDAS and PANS: a systematic review. Neurosci Biobehav Rev 2018;86():51-65. [PubMed]
- Nazeer A, Latif N, Mondal A ym, Obsessive-compulsive disorder in children and adolescents: epidemiology, diagnosis and management. Transl Pediatr. 2020 Feb; 9(Suppl 1): S76-S93 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082239/