Introduction
Epidemiology
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.
Presentation
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)
Diagnosis
Criteria
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.
Comorbidities
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 (39% and 53%).
- COMB group was superior to SER (21% remission rate) and placebo (3.6%).
2003 meta-analysis
Geller DA, et.al. 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 clomipramine vs. placebo, total n = 1044.
- 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)