Preparation for Child Psych PRITE and Boards
Jump to: navigation, search


Evaluation and treatment of adult OCD is addressed in a separate article.


OCD in children and adolescents often goes unrecognized and undiagnosed due to its idiosyncratic, not always obvious nature.

  • Point prevalence of pediatric OCD is 0.25% (British study 5-15 y.o., Heyman I, IntRevPsych 2003);
  • Overall pediatric prevalence rate is 1-2% (USA studies, Apter A, JAACAP 1996)
  • Incidence of OCD peaks during two developmental periods, pre-adolescents (mean 10 y.o.), and young adults (mean 20 y.o.). (Geller D, March J, Practice Parameter, JAACAP 2012)
  • Childhood onset of OCD is more common in boys with a 3:2 ratio, (Lewis text p.550) while M:F ratio of OCD in adults is 1:1.

Genetic and non-genetic factors

  • OCD has a significant familial/genetic component with higher concordance rates in monozygotic twins vs. dizygotic twins.
  • Environmental triggers and immunological cross-reactions, particularly to Strep infection had been implicated.
    • PANDAS - Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus, is attributed to immune response to Group A Strep, which can cause cross-reactivity and inflammation of basal ganglia. This can produce (the somewhat controversial) syndrome of PANDAS, which involves tics, OCD, and hyperactivity.

Developmental trajectory

  • Insistence on certain rituals and routines is common and normal in toddlers and pre-schoolers, as long as family functioning is not disrupted and a child can tolerate some disruption in the ritual (JACAAP parameter 2012)
  • Severity of pediatric OCD may diminish and become sub-clinical with time.
  • OCD is more likely to persist in youth with younger age of onset and longer duration of symptoms.
  • Also more likely to persist are religious, hoarding, and sexual subtypes of OCD.
  • Separation anxiety is a common comorbidity in children with OCD.


Children may have compulsions without obsessions.

Common obsessions

  • The most common obsessions in children and adolescents involve aggressive and catastrophic worries (e.g death of parent); these become less common in adults. (Geller DA, J Nerv Men D/o 2001)
  • Sexual and religious obsessions are more common in adolescents.
  • Contamination worries are common throughout the developmental spectrum.

Common compulsions

  • Most common compulsions across the developmental spectrum involve checking, cleaning, and ordering rituals.
  • Hoarding compulsions are more common in children in adolescents and become less common in adults. (Geller DA, J Nerv Men D/o 2001)



  • Children and adults need to have either obsessions or compulsions with marked distress, functional impairment (school, work, relationships) and taking >1hr/day.
  • To be diagnosed with OCD, adults must recognize their O&C to be excessive or unreasonable, at least at some point during the disorder. This level of insight is not necessary for the diagnosis in children (DSM-IV)


Children's Yale-Brown Obsessive Compulsive Scale(CY-BOCS) is based on adult Y-BOCS, a clinician-administered instrument, that assesses degree of impairment and distress from obsessions and compulsions. Range of cumulative OCD severity:

  • <7 - subclinical
  • 8-15 - mild illness
  • 16-23 - moderate illness
  • 24-31 - severe
  • 31-40 - extreme

Differential diagnosis

  • Pervasive developmental disorders involve stereotypies and rituals as the core criteria. OCD symtpoms are generally egodystonic and are accompanied by anxiety and fears.
  • Tourette's and tic disorders have significant comorbidity with OCD, and it is often difficult to distinguish complex tics from compulsions.


A number of disorders have overlapping symptoms or behavioral manifestations with OCD; they have been termed obsessive-compulsive-related disorders (Hollander E, J Clin Psych 1996)

  • preoccupation with bodily sensations or appearance: body dysmorphic disorder, anorexia nervosa, hypochondriasis.
  • impulsive disorders: sexual compulsions, trichotillomania and self-injurious behaviors, pathological gambling, kleptomania.
  • neurologic disorders: Tourette's and tics, torticollis, Sydenham's choreas, autism, PANDAS.

Treatment trials

POTS trial

The Pediatric OCD Treatment Study (POTS) was a 12-week randomized controlled trial (JAMA, 2004).

  • n=112 randomized to 4 groups (CBT alone, sertraline alone (SER), combination (COMB), and placebo);
  • Remission rates were statistically similar for CBT and COMB groups (bit clinically different 39% and 53%).
  • COMB group was superior to SER (21% remission rate) and placebo (3.6%).

2003 meta-analysis

Geller DA, Which SSRI? A Meta-Analysis of Pharmacotherapy Trials in Pediatric Obsessive-Compulsive Disorder (AM J Psych 2003)

  • pooled RCTs involving four SSRIs (paroxetine, fluoxetine, fluvoxamine, and sertraline) and SRI clomipramine vs. placebo, total n = 1044. It found statistically significant but modest effect size of 0.46
  • mean difference from the placebo: clomipramine > paroxetine = fluoxetine = sertraline = fluvoxamine > placebo
  • due to adverse effects of clomipramine, it should not be the first line treatment.
    • usually used after two failed SSRI trials
    • should be considered before second generation antipsychotics.

AACAP Practice Parameter

AACAP guidelines were updated in 2012 (JACAAP 51(1) 2012); recommendations were categorized by strength/amount of evidence as Clinical standard (CS) > Clinical Guideline (CG) > Opinion (O) > not endorsed (NE)

  • youth should be routinely screened for OC symtpoms (CG);
  • those with suspected OC symtpoms should be further evaluated using DSM-IV and CY-BOCS (CS), and have a full psychiatric, medical, developmental, and school evaluations (CG)
  • CBT is first-line treatment in mild to moderate OCD (CS) (meta-analysis (Watson HJ 2008 found large effect size: 1.45; >50% remission verify)
  • For moderate to severe OCD (CY-BOCS>23), a combination treatment of SRI medications (SSRIs, clomipramine) and CBT is indicated (CS)
    • Treatment should continue for 6-12 months after stabilization before a gradual taper is attempted. Children who relapse may require longer treatment.
    • Side effects of SRIs, particularly conversion to mania, suicidality, and cardiovascular effects of clomipramine should be carefully weighted.
  • Medication augmentation may be appropriate in treatment resistant cases (failed 2 SRIs trials x10 weeks each at max/tolerated dose x3weeks). (OP)

Treatment-resistant OCD

After failure of >3 SSRIs at therapeutic doses, the following can be helpful (AACAP workshop 2016)

  • augmentation with second-generation antipsychotic; this is particularly effective in youth with tics or schizotypal features.
  • using supre-therapeutc doses of SSRIs
  • augmentation with clomipramine

Black belt OCD

  • Youth with strong family history of OCD are less likely to respond to CBT alone; they are good candidates for combined treatment (Garcia JAACAP 2010)
  • common commorbidites (tics, ADHD, ODD) are associated with lower response rates and higher relapse when OCD is treated with an SSRI; CBT improves these outcomes. (March J Biol Psych 2007)