Obsessive-Compulsive Disorder (OCD

Children and teens with Obsessive-Compulsive Disorder (OCD) have unwanted thoughts, worries, or urges called obsessions. Obsessions are very upsetting and hard to control. They may also develop repetitive actions, called compulsions, to calm the distress from their obsessions. In kids, compulsions can happen even when obsessions are not obvious.

Often, compulsions are not connected to obsessions in a realistic way. For example, a child might have an obsessive fear that their parents will be in a car accident. To deal with that fear, they might turn a light on and off five times. Even if they know it doesn’t make sense, they feel that the ritual will keep their parents safe. Professionals call that feeling “magical thinking.”

What are the symptoms of OCD?

Kids and teens with OCD usually have both obsessions and compulsions. They use compulsions to control the anxiety that obsessions cause. Specific symptoms of obsessions and compulsions include:

More about Obsessions

– Obsessions are frequent and repeated thoughts, images, or urges that kids sometimes experience. Obsessions can interrupt daily activities, and often, people feel anxious about them, distressed, and they want them to stop.

– People try to suppress or ignore the thoughts, images, or urges, or to make them go away by thinking or doing something else.

Common Obsessions

– Thoughts about being dirty or “contaminated” by germs, waste, vomit, chemicals, etc.

– Needing everything to be even or symmetrical

– Extreme worry about safety, like thinking that the house will burn down, or a parent will get hurt

– Ideas that one might do something violent or terrible

More about Compulsions

– Compulsions are repeated actions (e.g., counting, praying, repeating words or phrases silently, etc.) or behaviors (e.g., checking, washing hands) that a person feels a need to do in response to an obsession or according to strict rules.

– The purpose of the repetitive acts or behaviors is to reduce or prevent the distress or anxiety, or to prevent a dreaded event, but they are not connected in a real way to what they are used to reduce or prevent.

Common Compulsions

– Washing their hands repeatedly

– Locking, unlocking, and re-locking doors a certain number of times

– Lining up objects or touching parts of their bodies symmetrically, like scratching both ears

– Counting a certain number of times or repeating something mentally

– Repeatedly asking parents for reassurance that something bad isn’t going to happen

How is OCD diagnosed?

A child-adolescent psychiatrist will diagnose a child or teen with OCD after checking if the obsessions and/or compulsions they are experiencing meet the diagnostic criteria; are time-consuming, taking more than one hour per day; and cause significant distress and problems in everyday life (e.g., social, school, etc.).

The child-adolescent psychiatrist may interview and/or assess both the child and a caregiver to figure out the specific nature of the child’s or teen’s obsessions and/or compulsions. Many practitioners also use specific questionnaires (e.g., Leyton Obsessional Inventory [LOI]) and scales (e.g., Children’s Yale-Brown Obsessive Compulsive Scale [CY-BOCS]) to support the diagnosis. The practitioner will also try to determine that the child’s or teen’s symptoms are not related to something unexpected.

OCD facts

Worldwide frequency of the condition:
OCD is present in between 1.1% and 1.8% of the world population.

Burden of the condition in Brazil:
There is a lack of nationally representative data on the prevalence of OCD in children and adolescents in Brazil. Local studies have found prevalence rates ranging from 0.1% to 3.2% in this age group.

Gender Ratio:
Comparisons between men and women vary greatly depending on the severity and variety of obsessive-compulsive symptoms. In general, boys are more likely to be diagnosed during childhood, while girls tend to experience OCD more frequently in late adolescence and beyond.

Peak age of onset:

The peak age for OCD onset is estimated to be 14.5 years. This number is similar to the peak age for onset of obsessive-compulsive disorders in general, which is also 14.5 years.

Proportion of the condition that emerges before age 18:
According to recent data, 45.1% of people with OCD are diagnosed before age 18. This figure is similar to that of obsessive-compulsive disorders in general, where the proportion is also 45.1%.

What are the associated factors for OCD?

Some common factors linked with OCD are:

– Genetic and familial factors: Most likely a combination of multiple genes interacting with environmental factors.

– Complications during pregnancy: These include maternal tobacco use during pregnancy.

– Environmental factors: These include stressful life events, such as abuse or other traumatic events, as well as parental overprotection.

– Infections and immune response: Pediatric acute-onset neuropsychiatric syndrome (PANS) results from a bacterial or viral infection, triggering an autoimmune response in certain children. Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) is a specific subtype of PANS resulting specifically from a streptococcal infection. The symptoms of PANS and PANDAS are sudden tics, OCD symptoms, and mood swings.

What other disorders co-occur with OCD?

Even though each child and teen is different, children and teens with OCD might often have other mental health problems, including anxiety disorders (e.g., Generalized Anxiety Disorder [GAD], Separation Anxiety Disorder, Social Anxiety Disorder, Panic Disorder, etc.), depressive disorders, and tic disorders.

How is OCD treated?

OCD is usually treated with therapy or a combination of therapy and medication. Caregivers and other family members are an important part of treatment, since they can help kids and teens practice the skills they learn in therapy. It is also important to involve family members in therapy for OCD, as they may unknowingly support a child’s symptoms through reassurance and participating in ritualistic behaviors (e.g., cleaning).

The most effective treatment for mild and moderate cases of OCD is cognitive-behavioral therapy (CBT), especially the CBT technique called exposure and response prevention (ERP). In this therapy, the therapist exposes the child or teen to small amounts of the thing that usually triggers their obsession. That way, kids practice dealing with their anxiety in a safe environment. The therapist then helps them avoid using their compulsion. Over time, kids feel less anxious, and they do not need the compulsion anymore. Kids with OCD will often return to their clinician in the years after their treatment for “booster sessions” to refresh the skills they learned to control their symptoms.

Children and teens with OCD tend to respond well to certain antidepressant medications called selective serotonin reuptake inhibitors (SSRIs). These include fluoxetine, sertraline, citalopram, escitalopram, paroxetine, and fluvoxamine. Other medications, such as clomipramine and serotonin and norepinephrine reuptake inhibitors (SNRIs; e.g., duloxetine and venlafaxine), have been used to treat OCD, but evidence of their efficacy for kids is limited. Medications can have side effects, but they are safe for kids to use with proper monitoring by their child-adolescent psychiatrist and close supervision from their caregivers. A child or teen taking one of these medications should see their doctor regularly, especially if their dosage has recently changed.

The combination of CBT and SSRIs should also be considered, since some studies show evidence that the combination is the best treatment compared to either treatment alone in children and teens.

References

Clinical description, symptoms, and diagnostic information

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Child Mind Institute. (2022, October 19). Complete guide to OCD. _https://childmind.org/guide/parents-guide-to-ocd/_

– World Health Organization. (2022, February). ICD-11 for mortality and morbidity statistics. 6B20 Obsessive-Compulsive Disorder. _https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1582741816_

Facts

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Baxter, A. J., Scott, K. M., Vos, T., & Whiteford, H. A. (2013). Global prevalence of anxiety disorders: A systematic review and meta-regression. Psychological Medicine, 43(5), 897–910. _https://doi.org/10.1017/S003329171200147X_

– Institute for Health Metrics and Evaluation (IHME). (2019). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington. Available from _http://vizhub.healthdata.org/gbd-compare_. (Accessed 11/15/2022)

Associated factors

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Arango, C., Dragioti, E., Solmi, M., Cortese, S., Domschke, K., Murray, R. M., Jones, P. B., Uher, R., Carvalho, A. F., Reichenberg, A., Shin, J. I., Andreassen, O. A., Correll, C. U., & Fusar‐Poli, P. (2021). Risk and protective factors for mental disorders beyond genetics: An evidence‐based atlas. World Psychiatry, 20(3), 417–436. _https://doi.org/10.1002/wps.20894_

– Ayano, G., Betts, K., Maravilla, J. C., & Alati, R. (2021). The risk of anxiety disorders in children of parents with severe psychiatric disorders: A systematic review and meta-analysis. Journal of Affective Disorders, 282, 472–487. _https://doi.org/10.1016/j.jad.2020.12.134_

– Brander, G., Pérez-Vigil, A., Larsson, H., & Mataix-Cols, D. (2016). Systematic review of environmental risk factors for Obsessive-Compulsive Disorder: A proposed roadmap from association to causation. Neuroscience & Biobehavioral Reviews, 65, 36–62. _https://doi.org/10.1016/j.neubiorev.2016.03.011_

– Child Mind Institute. (2023, February 23). Complete guide to PANS and PANDAS. _https://childmind.org/guide/parents-guide-to-pans-and-pandas/_

– Farhane-Medina, N. Z., Luque, B., Tabernero, C., & Castillo-Mayén, R. (2022). Factors associated with gender and sex differences in anxiety prevalence and comorbidity: A systematic review. Science Progress, 105(4), 003685042211354. _https://doi.org/10.1177/00368504221135469_

– Fullana, M. A., Tortella-Feliu, M., Fernández de la Cruz, L., Chamorro, J., Pérez-Vigil, A., Ioannidis, J. P. A., Solanes, A., Guardiola, M., Almodóvar, C., Miranda-Olivos, R., Ramella-Cravaro, V., Vilar, A., Reichenberg, A., Mataix-Cols, D., Vieta, E., Fusar-Poli, P., Fatjó-Vilas, M., & Radua, J. (2020). Risk and protective factors for anxiety and obsessive-compulsive disorders: An umbrella review of systematic reviews and meta-analyses. Psychological Medicine, 50(8), 1300–1315. _https://doi.org/10.1017/S0033291719001247_

– Gottschalk, M. G., & Domschke, K. (2017). Genetics of generalized anxiety disorder and related traits. Dialogues in Clinical Neuroscience, 19(2), 159–168. _https://doi.org/10.31887/DCNS.2017.19.2/kdomschke_

– Kendler, K. S. (2013). What psychiatric genetics has taught us about the nature of psychiatric illness and what is left to learn. Molecular Psychiatry, 18(10), 1058–1066. _https://doi.org/10.1038/mp.2013.50_

– Mahjani, B., Klei, L., Hultman, C. M., Larsson, H., Devlin, B., Buxbaum, J. D., Sandin, S., & Grice, D. E. (2020). Maternal Effects as Causes of Risk for Obsessive-Compulsive Disorder. Biological Psychiatry, 87(12), 1045–1051. _https://doi.org/10.1016/j.biopsych.2020.01.006_

– Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G., Il Shin, J., Kirkbride, J. B., Jones, P., Kim, J. H., Kim, J. Y., Carvalho, A. F., Seeman, M. V., Correll, C. U., & Fusar-Poli, P. (2022). Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry, 27(1), 281–295. _https://doi.org/10.1038/s41380-021-01161-7_

– Somers, J. M., Goldner, E. M., Waraich, P., & Hsu, L. (2006). Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature. The Canadian Journal of Psychiatry, 51(2), 100–113. _https://doi.org/10.1177/070674370605100206_

Co-occurring disorders

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Sharma, E., Sharma, L. P., Balachander, S., Lin, B., Manohar, H., Khanna, P., Lu, C., Garg, K., Thomas, T. L., Au, A. C. L., Selles, R. R., Højgaard, D. R. M. A., Skarphedinsson, G., & Stewart, S. E. (2021). Comorbidities in Obsessive-Compulsive Disorder Across the Lifespan: A Systematic Review and Meta-Analysis. Frontiers in Psychiatry, 12, 703701. _https://doi.org/10.3389/fpsyt.2021.703701_

Interventions

– Correll, C. U., Cortese, S., Croatto, G., Monaco, F., Krinitski, D., Arrondo, G., Ostinelli, E. G., Zangani, C., Fornaro, M., Estradé, A., Fusar‐Poli, P., Carvalho, A. F., & Solmi, M. (2021). Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: An umbrella review. World Psychiatry, 20(2), 244–275. _https://doi.org/10.1002/wps.20881_

– Ferrando, C., & Selai, C. (2021). A systematic review and meta-analysis on the effectiveness of exposure and response prevention therapy in the treatment of Obsessive-Compulsive Disorder. Journal of Obsessive-Compulsive and Related Disorders, 31, 100684. _https://doi.org/10.1016/j.jocrd.2021.100684_

– Gosmann, N. P., Costa, M. de A., Jaeger, M. de B., et al. (2021). Selective serotonin reuptake inhibitors, and serotonin and norepinephrine reuptake inhibitors for anxiety, obsessive-compulsive, and stress disorders: A 3-level network meta-analysis. PLoS Med, 18(6), e1003664. _https://doi.org/10.1371/journal.pmed.1003664_

– Kotapati, V. P., Khan, A. M., Dar, S., et al. (2019). The effectiveness of selective serotonin reuptake inhibitors for treatment of Obsessive-Compulsive Disorder in adolescents and children: A systematic review and meta-analysis. Front Psychiatry, 10, 523. _https://doi.org/10.3389/fpsyt.2019.00523_

– Plaisted, H., Waite, P., Gordon, K., & Creswell, C. (2021). Optimising Exposure for Children and Adolescents with Anxiety, OCD and PTSD: A Systematic Review. Clinical Child and Family Psychology Review, 24(2), 348–369. _https://doi.org/10.1007/s10567-020-00335-z_

– Skapinakis, P., Caldwell, D., Hollingworth, W., et al. (2016). A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive–compulsive disorder in children/adolescents and adults. Health Technol Assess, 20(43), 1-392. _https://doi.org/10.3310/hta20430_