Obsessive Compulsive Disorder in Children and Adolescents

There are many different kinds of obsessions and compulsions.  Some of the more common ones in children are:

• Fears of dirt, germs, or contamination, often associated with compulsive washing or cleaning.
• Fears of a catastrophic event, such as the death of a parent, often associated with compulsive checking or superstitious behaviors.
• Excessive scruples or guilt, often associated with compulsive mental rituals (such as praying in a certain way) or reassurance-seeking from adults.
• Excessive concern about order and symmetry, often associated with compulsive arranging or ordering.
• Unwanted, frightening, or repugnant thoughts or mental images, often associated with compulsive mental rituals or repeating behaviors.

OCD is characterized by abnormalities of brain function which are thought to contribute to symptoms.  In particular, evidence points to a hyperactive loop extending from the frontal cortex to the basal ganglia, which affects inhibition of thoughts and behaviors, modulation of emotion, and other aspects of the disorder.  In addition, compulsive behavior and avoidance of feared situations are thought to contribute to the persistence of obsessive fears.  OCD disorder has a genetic component, although having a genetic predisposition to OCD does not necessarily mean that someone will develop OCD.   

In a small number of pediatric OCD cases, OCD symptoms may result from exposure to a subtype of streptococcal infection.  In these cases, OCD onset is abrupt and accompanied by other symptoms, including a clear decline in handwriting and mathematical ability. 

First Line Treatments

• Cognitive-behavioral therapy consists of gradually exposing the child to feared objects, activities, or thoughts, while simultaneously refraining from compulsive behavior.  CBT for pediatric OCD usually includes parent interventions, which help parents more effectively manage their child's behavior and reduce anxiety symptoms.
• For moderate to severe OCD, antidepressant medications, which are thought to help by improving the amount of serotonin in the brain, are recommended as an adjunctive treatment for CBT. Specific first-line medications for pediatric OCD are selective serotonin reuptake inhibitors (SSRIs) including:
• Sertraline
• Fluvoxamine
• Fluoxetine
• Paroxetine

Other Effective Treatments

In cases of nonresponse to first-line treatment, alternative treatments with reasonable evidence of efficacy include:

• Monotherapy with antidepressant medications such as clomipramine
• Augmentation of SSRI medication with clomipramine
• Combined CBT and SSRI treatment (note: this is the first-line treatment for moderate to severe pediatric OCD)

In addition, research suggests that the following treatments are promising:

• Augmentation of SSRIs with clonazepam, atypical neuroleptic medications, or stimulant medications
• Monotherapy with the glutamatergic medication riluzole
• D-cycloserine augmentation of CBT