OCD

Obsessive Compulsive Disorder in Children and Adolescents

Although OCD in adults has been well studied and the disorder was known to occur in childhood, the high prevalence of OCD in children and adolescents was not recognized until the 1980s (Geller, 2006). A previously mentioned epidemiological study by Flament et al. (1988) revealed that OCD was much more common in the younger population than once thought, highlighting that the disorder was being underdiagnosed and left untreated in children and adolescents. One reason for the lack of recognition of OCD in children and adolescents is that symptoms of OCD were considered a normal part of development (Flament and Cohen, 2000), a view that changed as research on adult patients revealed that as many as half reported the onset of symptoms at a young age (Rasmussen and Eisen, 1990).

 

The mean age of onset in children and adolescents is 10.3 years, with some studies finding an earlier age of onset for boys than for girls (Geller et al., 1998). The onset of OCD in children and adolescents can be either gradual or acute, with up to 38% of patients or their families describing the onset of symptoms as a result of a specific event, such as a stressful family event (Rettew et al., 1992). The specific clinical correlates, as well as peaks in the emergence of OCD symptoms at a young age and again in adulthood, have led some researchers to suggest that OCD in children and adolescents might be a developmental subtype of the disorder (Geller et al., 1998). In a subgroup of children and adolescents, OCD has been seen to suddenly emerge in association with a streptococcal infection, a subtype of OCD that has been classified as a pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections, or PANDAS for short (Bernstein et al., 2010). Early onset OCD is shown to be highly familial more frequently associated with tic disorders (Hanna et al., 2011).

Bernstein, G.A., Victor, A.M., Pipal, A.J., Williams, K. a, 2010. Comparison of clinical characteristics of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and childhood obsessive-compulsive disorder. J. Child Adolesc. Psychopharmacol. 20, 333–340. doi:10.1089/cap.2010.0034
Flament, M.F., Cohen, D., 2000. Child and Adolescent Obsessive-Compulsive Disorder: A Review, in: Obsessive-Compulsive Disorder. John Wiley & Sons, Ltd, Chichester, UK, pp. 147–201. doi:10.1002/0470846496.ch4
Geller, D.A., 2006. Obsessive-Compulsive and Spectrum Disorders in Children and Adolescents. Psychiatr. Clin. North Am. 29, 353–370. doi:10.1016/j.psc.2006.02.012
Geller, D., Biederman, J., Jones, J., Park, K., Schwartz, S., Shapiro, S., Coffey, B., 1998. Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature. J. Am. Acad. Child Adolesc. Psychiatry 37, 420–7. doi:10.1097/00004583-199804000-00020
Hanna, G.L., Himle, J. a., Hanna, B.S., Gold, K.J., Gillespie, B.W., 2011. Major depressive disorder in a family study of obsessive-compulsive disorder with pediatric probands. Depress. Anxiety 28, 501–508. doi:10.1002/da.20824
Rasmussen, S.A., Eisen, J.L., 1990. Epidemiology of obsessive compulsive disorder. J. Clin. Psychiatry 51 Suppl, 10–3; discussion 14.
Rettew, D.C., Swedo, S.E., Leonard, H.L., Lenane, M.C., Rapoport, J.L., 1992. Obsessions and compulsions across time in 79 children and adolescents with obsessive-compulsive disorder. J. Am. Acad. Child Adolesc. Psychiatry 31, 1050–6. doi:10.1097/00004583-199211000-00009

 

Clinical Definition of OCD

The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) provides clinicians with official definitions of and criteria for diagnosing mental disorders and dysfunctions. These criteria are based on years of research and clinical experience. Below you can see the criteria for OCD included in the DSM-5.

DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder (300.3)

A.    Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

2.The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

2.The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

Specify if:

With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.

With poor insight:  The individual thinks obsessive-compulsive disorder beliefs are probably true.

With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.

Specify if:

Tic-related: The individual has a current or past history of a tic disorder.

 

 

How to get help if you suspect that you or your child has OCD?

The first step on the way to get help can be to discuss your worries with your family physician as he can refer you to the best available treatment based on where you live. The recommended first line of treatment for children and adolescents is cognitive-behavioral therapy (CBT), but this is usually administered by a qualified psychologist or psychiatrist. The essence of CBT for OCD is to expose the patient to the things he fears while at the same time prevent the usual response to those fears, such as excessive hand washing after exposure to “contaminated” things or places. Although this may provoke anxiety at first, this will diminish as treatment progresses. For some patients CBT is not enough and needs to be supplemented with medication.

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