IACAPAP Textbook of Child and Adolescent Mental Health

ANXIETY DISORDERS

Chapter

F.3

OBSESSIVE COMPULSIVEDISORDER IN CHILDREN AND
ADOLESCENTS
Pedro Gomes de Alvarenga, Rosana Savio Mastrorosa &Maria Conceição do Rosário
Pedro Gomes de Alvarenga
MD
Psychiatrist, Department
and Institute of Psychiatry,
University of São Paulo Medical
School, São Paulo, Brazil.
Conflict of interest: none
disclosed

Rosana Savio Mastrorosa
BA
Clinical Psychologist, Childand Adolescent Psychiatry
Unit (UPIA), Department of
Psychiatry, Federal Universityof São Paulo, São Paulo, Brazil
Conflict of interest: none
disclosed

Maria Conceição do Rosário
MD, PhD
Child and Adolescent
Psychiatrist; Associate
Professor at the Child andAdolescent Psychiatry unit
(UPIA), Department of
Psychiatry, Federal Universityof São Paulo, São Paulo, Brazil
Conflict of interest: speaker forNovartis, Lilly and Shire
This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Alvarenga PG, Mastrorosa RS , Rosário MC. Obsessive compulsive disorder in children and adolescents. In Rey
JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent
Psychiatry and Allied Professions 2012.

OCD

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IACAPAP Textbook of Child and Adolescent Mental HealthObsessive-Compulsive Disorder (OCD) is a common neuropsychiatricdisorder characterized by the presence of obsessions and/or compulsions
that are time consuming and cause distress or interference in the patient’s
life (American Psychiatric Association, 2000). OCD affects all age groups
independent of race, socioeconomic status or religion. Moreover, OCD has been
estimated to cost approximately 8 billion dollars per year in the US (Hollander etal, 1998). Despite being frequent and disabling some studies suggest that almost
60% of OCD patients wait too long to seek treatment or do not receive treatment
due to a lack of health professionals trained to identify OCD (Dell’Oso et al,2007).
Pediatric OCD may resemble adult OCD but often presents particularclinical features. Recent studies support the idea that OCD is clinically andetiologically heterogeneous and that early-onset OCD may represent a uniquesubgroup (Miguel et al, 2005; Leckman et al, 2009). Furthermore, in 50% to
80% of OCD cases symptoms start before 18 years of age, which highlights theimportance of understanding OCD as a developmental disorder (Kessler et al,2005). The objective of this chapter is to present the more relevant issues on theevaluation and management of children and adolescents with OCD.

HISTORICAL OVERVIEW
Obsessive-compulsive symptoms have been identified since the 17th
century. At that time, obsessions and compulsions were described as manifestationsof religious melancholy and sufferers were considered to be “possessed” by outside
forces. By the first half of the 19th century, OCD shifted into the scientific field.
Jean Dominique Esquirol, a French psychiatrist, was the first to describe in 1838a medical disorder quite similar to contemporary OCD and classified it as a“monomania” (a kind of partial delusion). At the end of the 19th century, OCD
was classified as neurasthenia. As the 20th century began, both Sigmund Freud andPierre Janet, a French psychologist, isolated OCD from neurasthenia. In 1903
Pierre Janet proposed that obsessional patients possessed an abnormal personality(called “psychastenia”), with features such as anxiety, excessive worrying anddoubting, and described the successful treatment of compulsions and rituals withtechniques that are similar to the ones used currently in behavioral therapy. Janet
reported the case of a five-year old “psychastenic” boy with intrusive and repetitive
thoughts. This is considered to be the first clinical description of pediatric OCD(for a review, see Alvarenga et al, 2007).
Currently, both the Diagnostic and Statistical Manual of Mental
Disorders (DSM; American Psychiatric Association, 2000) and the International
Classification of Diseases (ICD; World Health Organization, 1992) use the same
diagnostic criteria for children, adolescents and adults, except that children are notrequired to have “insight”. A revision of these classifications is taking place.

EPIDEMIOLOGY
Lifetime prevalence of OCD is 1% to 3% making it one of the mostprevalent neuropsychiatric disorders. OCD symptoms start before puberty inapproximately one third to one-half of sufferers (Kessler et al, 2005). For instance,a study comprising 330 adult patients with OCD found that 49% presented theirfirst symptoms before 11 years of age and 23% between 11 and 18 (de Mathis et al,2009). In children and adolescents, OCD was considered to be rare until a study
published in 1988 estimated a one year prevalence of 0.7% in the US (Flament
et al, 1988). The more recent British child mental health survey reported a point
prevalence of 0.25% among 5- to 15-year-olds; remarkably, most of the cases had
never looked for treatment – similar to the results of adult epidemiological studies(Heyman et al, 2003).

OCD

F.3

Jean Dominique Esquirol, aFrench psychiatrist, was thefirst to describe in 1838 a
medical disorder quite similar
to contemporary OCD

Impact of obsessive
compulsive disorder
•
•
•
•
•

OCD is a common
neuropsychiatricdisorderCauses substantial
suffering and disability
Costs approximately 8billion dollars per year
in the US
Onset in 50% to 80%
of cases is before 18
years of age
Almost 60% of patientsremain with symptoms.

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IACAPAP Textbook of Child and Adolescent Mental Health

The incidence of OCD has two peaks with different gender distributions;the first peak is in childhood, with symptoms mostly arising between 7 and 12
years of age and a male preponderance. The second peak occurs in early adulthood,at a mean age of 21 years and with a slight female majority (Geller et al, 1998).

CLINICAL FEATURESOCD is characterized by the presence of obsessions or compulsions
that are time consuming (at least one hour per day), cause subjective distress orinterfere with the patient’s or the family’s life. Obsessions are intrusive, unwanted
ideas, images, fears, thoughts or worries that are experienced as uncomfortable,
unpleasant, distressing or anxiety provoking. Compulsions are repetitive behaviors
or mental acts performed to ignore, reduce or eliminate the anxiety or distresscaused by the obsessive thoughts. Compulsions are usually executed according tocertain rules the patient feels driven to follow (American Psychiatric Association,2000). Obsessive compulsive symptoms vary considerably not only from patientto patient but also in the same patient over time. Despite this variation, some
symptoms are more frequent than others and are described in Table F.3.1.
Even though there are many similarities in the clinical presentation acrossthe lifespan, children and adolescents with OCD also show specific features.
For instance, the younger the patient the higher is the probability of having
compulsions without obsessions (Rosario-Campos et al, 2001). Children are alsoless likely to recognize their symptoms as ego dystonic, making them less willing
to resist the urge to perform a compulsive behavior. Therefore, DSM-IV does not
require children to have insight to qualify for the diagnosis. Children may alsopresent tic-like compulsions, which may be confused with complex tics, mainly if
the compulsions are simple rituals of touching (Rosario-Campos et al, 2005). In
these cases, compulsions may be preceded or accompanied not only by obsessions
but also by various types of sensory phenomena.

The Oxford Don, Robert
Burton, reported a case in hiscompendium, the Anatomyof Melancholy (1621): "If he
be in a silent auditory, as at a
sermon, he is afraid he shallspeak aloud and unaware,something indecent, unfit tobe said."

Sensory phenomena is a term used to define uncomfortable or disturbing
sensations, perceptions, feelings or urges that either precede or accompany
repetitive behaviors such as compulsions or tics. OCD patients might feeldriven to repeat compulsions until they experience a sense of relief from these
uncomfortable sensations. Sensory phenomena can be divided into physical andmental. Examples include sensations in the skin, “just-right” perceptions, andfeelings of incompleteness (Rosario et al, 2008; 2009). For instance, people can“feel” an oily sensation on their hands and wash them repeatedly for this reason.
Another person may feel “uncomfortable” with the way some objects are arranged
on a shelf and may feel an urge to arrange them many times, until they look“just right”. Evaluation of the presence and severity of sensory phenomena isrelevant because some studies have reported that patients with early-onset and ticrelated OCD show more sensory phenomena and some report that these sensory
phenomena cause even more distress than the compulsions.
Age at onset
So far, there is no consensus on how best to define age of onset; someauthors define it as the age when symptoms began (Rosário-Campos et al, 2001)
while others define it as the age when symptoms started to interfere with normal
functioning (Tükel et al, 2005). Also, there is no agreement about the best cutoff age for the early-onset subtype; cut-offs at age 10, 14 or 18 years have been
proposed (Rosario-Campos et al, 2001). A study of comorbidity in 330 OCD
patients shed some light on this question; the authors reported that including
age at onset in the analyses as a continuous variable was most informative andthat 10 and 17 years were appropriate cut-offs for early and late onset subgroups
respectively (de Mathis et al, 2008).

OCD

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3

IACAPAP Textbook of Child and Adolescent Mental HealthAge at onset is important because there is emerging evidence that earlyonset OCD may represent a distinct subtype of the disorder. Previous research has
shown that adults who report an early onset display greater severity and persistenceof symptoms and may be less responsive to treatment. Moreover, early-onset has
been associated with fewer obsessions, more tic-like compulsions, more sensory
phenomena, and a higher rate of comorbid tic disorders (Rosario-Campos et al,
2001; de Mathis et al, 2009).
Obsessive-compulsive symptom dimensions
		 Even though subdividing patients according to age of onset has provento be useful in identifying more homogenous subgroups, a dimensional approachhas proven to be of even greater value. Factor-analytic studies have reduced
OCD symptoms to a few consistent and clinically meaningful dimensions:contamination/cleaning, obsessions/checking, symmetry/ordering, and hoarding(Mataix-Cols et al, 2005).
		 These symptom dimensions, which are similar in all age groups (Blochet al, 2008), can be understood as overlapping clinical features that may becontinuous with "normal" worries first evident in childhood (Leckman et al,2009), are temporally stable, and correlate with various genetic, neuroimaging andtreatment response variables (Mataix-Cols et al, 2005).
For instance, some studies have reported that early-onset OCD patientsshow higher severity in the following symptom dimensions: aggressive obsessions
and related compulsions; sexual and religious obsessions and related compulsions;and symmetry, ordering and arranging obsessions and compulsions (RosárioCampos et al, 2005; Leckman et al, 2009).
Comorbidity
Similar to adults with OCD, 60% to 80% of affected children andadolescents have one or more comorbid psychiatric disorders. Some of the mostcommon are tic disorders, attention deficit hyperactivity disorder (ADHD), otheranxiety disorders, mood and eating disorders (Geller, 2006).
The association between OCD and tic disorders is the most striking.
OCD children have reported rates of tics ranging from 20% to 59%, compared to
9% and 6% in adolescents and adults, respectively. Similarly, 48% of early-onset
adult OCD patients have tics or Tourette’s syndrome, compared to 10% of thosewith a late-onset (Rosario-Campos et al, 2001). The impact of this association
has led some to describe a “tic-related OCD” subgroup, characterized by a higher
risk of transmission of both subclinical OCD and tics among first-degree relativesof OCD probands; higher male frequency; earlier age at onset; and a differential
treatment response (Rosario et al, 2008).
Moreover, there is a group of disorders that seems to represent a clinicalcontinuum (i.e., intrusive thoughts, anxiety and repetitive behaviors) and toshare genetic and physiopathologic mechanisms with OCD. These disorders havebeen named obsessive-compulsive spectrum disorders and include OCD, body
dysmorphic disorder, tic disorders, trichotillomania, and impulse control disorders(Bienvenu et al, 2012).
Course and outcome
The course of OCD is heterogeneous. The onset of symptoms can be
abrupt or insidious, and content varies considerably from patient to patient. It isalso frequent for symptoms to change over time, even though they often maintaina certain thematic consistency (Miguel et al, 2005).

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IACAPAP Textbook of Child and Adolescent Mental Health

Table F.3.1 Common obsessions and compulsions
OBSESSIONS
Injury, violence, aggression or natural disaster:•••

Recurrent, anxious thoughts or images that they
may hurt themselves or other people (for example,
when in contact with sharp objects or next to awindow)Fear of obeying aggressive impulses
Fear of not performing certain rituals (usuallychecking or avoidance) and as a consequencesomething bad may befall to people who are dear
and the consequent responsibility for that.

Sexual and Religious:••“Forbidden” or “improper” sexual thoughts, images,
or impulses
Extreme concern about sinning or doing somethingmorally wrong, saying or doing something religiously
not acceptable

COMPUSIONS OR RITUALS
Checking or avoidancedue to Injury, violence,
aggression or natural d isaster obsessions:
•
•
•
•
•

Checking or avoidance due to sexual, religious, or
morality obsessions:
•
•
•
•
•

Worries or preoccupations or a need forsymmetry, order and arranging:••

Need for things to be symmetrical or balanced
Need for things to be perfect, exact or “just-right”

Repeatedly checking doors, locks, stove, windows
Checking whether they injured themselves or otherpeopleVerifying whether something bad did happen
Checking or taking other measures to prevent or avoid
harm coming to them or others
Need to repeat routine activities to prevent bad
consequences.

Making sure that they have not done anything wrong ofa sexual/ religious nature
Avoiding certain actions, people, places or objects toprevent sexual or religious obsessions and compulsions
from occurring
Need to repeat activities to prevent bad consequences
Need to generate "good" thoughts to compensate for or
override "bad" thoughts
Silently counting, repeating phrases or praying

Repetition, order, arranging••••

Arranging objects many times until they are
symmetrically aligned or matched
Counting objects like ceiling or floor tiles, books in a
bookcase, nails in a wall, or even grains of sand on thebeach
Straightening pa­per and pens on a desktop or books ina bookcase
Touching or doing something on the right side followedby the compulsion to touch or do the same thing on theleft side

Contamination; obsessed about getting ill or
injured as a result of:

Checking, avoidance or repetition,  excessive or
ritualized:

•
•

•
•

•
•
•
•

Dirt or germs
Bodily waste or fluids (like vomit, urine, feces orsaliva)Environmental contaminants (like asbestos,radiation, or toxic waste)
Insects or animals
Sticky substances or residues
Household items or other inanimate objects•••

Cleaning or washing of body parts or objects
Showers, baths, and other bathroom routines, which
need to be done in a certain order
Excessive use of toilet tissue
Compulsion to perform the whole process again if thesequence of washing or cleaning is interrupted
Avoidance of touching objects, animals or people
because they may be dirty or contaminatedCollecting and hoarding:Hoarding or collecting:  

•

•

•

OCD

Fear of getting rid of unimportant objects believing
they will be needed in the future
Inability to decide throwing things away

F.3•

Rooms filled with old newspapers, notes, cans, paper
towels, wrappers or empty bottles
Picking up objects or trash from the street or fromgarbage cans.

5IACAPAP Textbook of Child and Adolescent Mental Health

Similar to what happens in adults, a long time may elapse until the
diagnosis is made and treatment started. Studies have reported an average of 2.5
years from the onset of symptoms to diagnosis in the US (Geller et al, 2006)
and even longer in Germany (Walitza et al, 2011). One of the reasons for this
delay is secrecy. Patients often feel ashamed or guilty about their symptoms or
behaviors and conceal them until they interfere with their daily functioning. Mildor moderate cases may only be diagnosed through indirect signs like an increasein the time needed to complete school tasks, isolation, or severely chapped skin asa result of washing compulsions (Rosario et al, 2008). In other cases, symptoms
may resemble normal childhood routines. In fact, some repetitive behaviors may
be normal in some developmental stages. Young children engage in a significant
amount of ritualistic, repetitive, and compulsive-like activities that appear to be partof their normal behavioral repertoire; they often have a rigid routine at bedtime,
mealtimes and at school. Various aspects of children's ritualistic and compulsivelike behaviors have been associated with children's fears and phobias. Therefore,
OCD could be conceptualized as a pathological condition with continuity withnormal behaviors during different developmental periods (Evans et al, 2002).
A 9-year longitudinal study assessing 145 children and adolescents with
OCD revealed that the most common diagnoses at follow-up were generalized
anxiety disorder (25%), followed by depressive disorders (16%) and a tic disorders(16%). Approximately two-thirds rated themselves as very much or much improvedin relation to their OCD. Almost half (49%) of the participants reported that theyneeded further treatment. The largest predictor of persistence of OCD at followup in this sample was duration of the illness. Severity at baseline did not predictpersistence. The impact of OCD on functional impairment and quality of life
was mild to moderate (Micali et al, 2010). These findings suggest that pediatric
OCD is a chronic or relapsing/remitting disorder that has long-term treatment
implications. Other studies have shown that some children become subclinicalover time (Stewart et al, 2004) and that children have a very favorable outcome
when treated early (AACAP, 2012).

Click on the picture to viewa general description of CBT(06:07)

Clinical assessment
Considering the secrecy surrounding OCD symptoms, it is important forfamily members to pay attention to early signs of ritualistic behaviors becoming
troublesome. Table F.3.2 lists some questions that may help screening for OCD.
Table F.3.2 Screening questions to help in the identification of obsessive
compulsive symptoms
Has your child ever shown:•

Concerns about catching a disease after touching something or unduly worrying
about dirt, leading to repetitive hand washing?

•

A preoccupation with ordering or arranging things so much so that it interferes withnormal life of schooling?

•

A need for things to look, feel or sound “just right”?

•

Excessive worries, fears or concerns with aggressive, sexual or religious thoughts?

•

An excessive need to collect or hoard objects?

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IACAPAP Textbook of Child and Adolescent Mental Health

Table F.3.3 Scales used in the evaluation of OCD patients
CY-BOCSDYBOCSYGTSS

USP-SPS

FAS

Author (Year)

Scahill et al(1997)

Rosario-Campos
et al (2006)

Leckman et al(1989)

Rosario et al(2008)

Calvocoressi et al(1999)

Aims

Assesspresence andseverity ofobsessions andcompulsions

Assess presence
and severity of
OCD symptom
dimensions

Assesspresence andseverity of tics

Assesspresenceand severityof sensory
phenomena

Assess levelsof family
accommodation

Administrationtime

15 minutes(excludingtime to goover symptom
checklist)

10 minutes foreach dimension
or 15 minutes foroverall severity(excluding time togo over symptom
checklist)

20 minutes

20 minutes(excludingtime to goover symptom
checklist)

20 minutes(excluding time togo over symptom
checklist)

Self-report

No

No

No

No

No

Valid andreliable

Yes

Yes

Yes

Yes

Yes

Clinically useful

Yes

Yes

Yes

Yes

Yes

Useful for
research

Yes

Yes

Yes

Yes

Yes

Available inlanguages otherthan English

Yes

Yes

Yes

Yes

Yes

(excludingtime to goover symptom
checklist)

CYBOCS: Children´s Yale-Brown Obsessive-Compulsive Scale; DYBOCS: Dimensional Yale-Brown Obsessive-Compulsive
Scale; USP-SPS: University of São Paulo Sensory Phenomena Scale; YGTSS: Yale Global Tic Severity Scale; FAS: Family
Accommodation Scale.

When OCD is suspected, a comprehensive clinical evaluation – including
detailed interviews with parents and, if possible teachers – is required in order toassess the compulsions, obsessions and sensory phenomena. In younger children,
OCD features might appear subtly during play activities or drawing. It is vitalto differentiate between obsessive compulsive symptoms and normal childhood
ritualistic behavior, typical of specific developmental phases, such as mealtime
or bedtime rituals. In this regard, detailed information about degree of distress,
impairment and time consumed performing rituals should provide enough data
to decide whether or not treatment is warranted. Moreover, it is also important toassess insight and the family’s perception of the symptoms, as well as how family
members deal with the patient.
Rating scales are useful to obtain detailed information regarding OCD
symptoms, tics, and other aspects relevant to the diagnosis. Scales are also used
to assess severity at baseline and to evaluate improvement in a more objective
way during follow up treatment. Some of these instruments are listed on Table
F.3.3, which are in the public domain and can be obtained from the authors uponrequest.

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IACAPAP Textbook of Child and Adolescent Mental Health

ETIOLOGICAL FACTORS
Factors that increase the risk of OCD are summarized in Table F.3.4 .
Genetic
Contrary to what was believed for many years − that OCD was essentiallyan environmentally caused illness − twin, family, segregation and linkage studies
have shown that OCD runs in families and this is largely accounted for by genetic
factors, with heritability in the range of 45% to 65% (van Grootheest et al, 2005).
Genetic-family studies have shown that the earlier the onset of OCD symptoms in
the probands the higher the risk for first-degree family members to have obsessive
compulsive symptoms, OCD, tics or Tourette’s disorder (Rosario-Campos
et al, 2005). Conversely, twin studies have shown that concordance rates formonozygotic twins are significantly higher than for dizygotic twins. Consideringthat concordance rates are not 100%, genetic studies also demonstrate that nongenetic factors are also important in the etiology of OCD.
Genetic linkage studies have identified regions of the genome likely tocontain susceptibility loci for OCD on chromosomes 1q, 3q, 6q, 7p, 9p, 10p,
and 15q. Many candidate gene studies have been conducted, mostly focusing onserotonergic, glutamatergic and dopaminergic genes although without conclusive
findings so far. Among all the polymorphisms that have been studied, some relevant
findings involve glutamatergic expression and have been correlated with repetitive
behaviors in humans and rodents (Miguel et al, 20005; AACAP, 2012).

Familyaccommodation•

Parents (and otherrelatives) facilitate orparticipate in children
obsessive-compulsive
symptoms•

Family accommodation
reinforces symptoms
and is associated withpoor outcome•

Examples of family
accommodation
include among others
parents answering
doubting questions
repetitively; notinterrupting or limiting
time-consuming
washing tasks; helping
children in ordering or
hoarding rituals.

Non-genetic
In predisposed subjects, environmental factors, such as emotional stressand traumatic brain injury may trigger OCD. Excessive weight gain during
gestation; prolonged labor; preterm birth; and jaundice have been associated withthe expression of OCD later in life (Vasconcelos et al, 2007).
Table F.3.4 Factors that increase the risk of OCD
Genetic••

Family••Individual•••

Environmental

•

•

OCD

F.3

Family members with obsessive compulsive symptoms, OCD
or tics
Promising candidate genes: SLC1A1 and SAPAP
Family history of OCD or OCD spectrum disorders (e.g., tic
disorders, tricotillomania, body dysmorphic disorder)
High familial accommodation to obsessive-compulsive
symptoms
Presence of obsessive-compulsive symptoms and subclinical
OCD
Neuropsychological abnormalities (global cognitive deficits,
mental inflexibility, visual spatial deficits, impaired motor skills)
Comorbid psychiatric disorders (e.g., Tourette’s syndrome)
Prenatal, perinatal and postnatal factors, e.g., excessive
weight gain during gestation; prolonged labor; preterm birth;jaundice emotional stress, traumatic brain injury, exposure to
substances (alcohol, cocaine, stimulants, and hormones) inearly pregnancy
Streptococcal infections and rheumatic fever

8IACAPAP Textbook of Child and Adolescent Mental HealthGroup A β-hemolytic streptococcal (GABHS) infection
The association between GABHS infection and rheumatic fever (asystemic autoimmune disease triggered by GABHS infection) and the onset or
worsening of OCD or tics has received considerable attention during the last two
decades. It is hypothesized that a GABHS infection in a susceptible host initiates
the production of autoantibodies that cross-react with the cellular components ofthe basal ganglia (Mercadante et al, 2005). This hypothesis, which applies only toa small proportion of children who develop OCD, is supported by neuroimaging
and immunological findings. OCD and other neuropsychiatric disorders are
more common than expected in first degree relatives of rheumatic fever probands(Hounie et al, 2007).
Familial factors
Another important non genetic factor is the family. Younger children are
more prone to involve relatives in their rituals, leading to higher levels of family
accommodation. While some try to stop the child from performing the rituals,
others “accommodate” or even reinforce the symptoms (Amir et al, 2000; McKay
et al, 2006).
Neurobiological substrates
It has been hypothesized that there is a dysregulation of fronto-corticostriato-thalamic circuits in OCD patients. Functional neuroimaging studies haveshown that the orbitofrontal cortex, anterior cingulate and striatum are hyper
activated in OCD patients and that this activation decreases after treatment(Friedlander et al, 2006; Rotge et al, 2008).
Neuropsychological tests have found deficits in mental flexibility and motor
skills, visuospatial abilities, and some forms of executive functioning in individuals
with obsessive compulsive symptoms and OCD (Mataix-Cols et al, 2008). Someof these deficits have also been found in first-degree relatives of OCD patients(Chamberlain et al, 2005). It has been suggested that some neuropsychologicalchanges observed in childhood, such as deficits in visuospatial abilities, may be an
early indication of risk for the development of OCD in adulthood (Grisham et al,2009).

Freud believed that
OCD was the patient's
maladaptive response
to conflicts between
unacceptable, unconscious
sexual or aggressive id
impulses and the demandsof conscience and reality,
regressing to concerns
about control and to modesof thinking characteristic of
the anal-sadistic stage ofpsychosexual development:
ambivalence, which
produced doubting, magicalthinking, and superstitious
compulsive acts.

The serotonergic system seems to be involved in the pathophysiologyof OCD − many trials have demonstrated a decrease in symptoms with the useof serotonergic drugs (Bloch et al, 2006). Peripheral serotonergic alterations are
frequently observed in adolescents and adults with OCD (Delorme et al, 2005).
Beyond the monoamine systems, some researchers suggest that oxytocin may also
play a role (Leckman & Herman, 2002).

TREATMENT
Before starting treatment it is extremely important to take into considerationsome relevant issues such as the correct identification of the most troublesome
OCD symptoms, how long the patient has had the illness, impact on the patient’s
life and difficulties working with the family (Table F.3.5). A thorough assessment,
involving both the patient, family members and school, is extremely important.
Another important issue is an accurate assessment of comorbid conditions thatusually accompany OCD. Comorbid conditions, if not evaluated or detected, cancomplicate treatment (Rosario et al, 2008).
Similar to the treatment recommendations for adults, treatment of
OCD in children and adolescents relies on cognitive behavioral therapy (CBT),
medication and psychoeducation. Both selective serotonin reuptake inhibitors(SSRIs) and CBT have been systematically studied and empirically shown to be
useful in the treatment of children and adolescents with OCD.

OCD

F.3

OCD treatment
guidelines
NICE: Obsessive compulsive
disorder (OCD) and body
dysmorphic disorder (BDD)(CG31) (November 2005)
AACAP: Practice parameterfor the assessment andtreatment of children andadolescents with obsessive
compulsive disorder (January
2012)

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Table F.3.5
Issues that need to be clarified during assessment andbefore treatment
Age of onset•

Age when symptoms were first noticed by thepatient or family

Degree of suffering,
impairment and time
consumed performing
rituals••

Important to distinguish OCD from transient
obsessive or compulsive behaviors seen in thecourse of normal development.
Rating scales might aid in this task.

Insight•

Poor insight is common in pediatric patients

Presence of sensory
phenomena•

Mental or physical premonitory urges often
occur instead of obsessions.

Family attitude towards theillness•

Excessive criticism or high levels ofaccommodation of symptoms are associatedwith poorer outcome

Are there comorbid
disorders?

•

Evaluate for the presence of comorbid
conditions (e.g., anxiety disorders, mooddisorders, tic disorders, ADHD, alcohol andother substance use disorders).

History of psychiatricdisorder in the family•

Are family members affected with OCD or otherpsychiatric disorders?

Non-pharmacological treatment
CBT is the only psychological therapy shown to be effective in thetreatment of childhood OCD (Rosario et al, 2008). Treatment of pediatric OCD
should preferably start with CBT for mild to moderate cases, or a combination of
CBT and pharmacotherapy for more severe cases, or when CBT is not available(Abramowitz et al, 2005; O´Connor et al, 2006; Walsh & McDougle, 2011).

CBT manuals
and self-help
books available
for therapists andfamilies interested
in these techniques(AACAP, 2012):•

Talking Back to
OCD: The Programthat Helps Kids andTeens Say “No Way”
and Parents Say“Way to Go” by John

March

•

Obsessive
Compulsive
Disorders: A
Complete Guide to
Getting Well andStaying Well by Fred

Penzell•Freeing Your Child
from Obsessive
Compulsive Disorder

by Tamar Chansky•

What to do
When your Child
has Obsessive
Compulsive
Disorder: Strategies
and Solutions, byAureen Pinto Wagner

The CBT theory of OCD integrates behavioral theory with a cognitive
framework and has shown significant efficacy especially when in combination with
exposure, response prevention, and cognitive restructuring. A meta-analysis has
shown mean effect sizes of CBT up to 1.45 (confidence interval 0.68-2.22) despite
the heterogeneity of the sample (Watson & Rees, 2008). Cognitive restructuring
helps patients realize the influence of thoughts and beliefs on behavior (rituals
and avoidance), the functional relationship between obsessions and rituals, andstrategies to neutralize them while causing relief. The behavioral model uses
exposure and response prevention techniques based on the relationship between
obsessions and compulsions, with the purpose of weakening the associationand the distress caused by them. It exposes the sufferers to the objects, peopleor situations they fear, and prevents them from performing the compulsion, inorder to gradually reduce the anxiety level (Abramowitz et al, 2005). Cognitiveand behavioral techniques complement each other and the power of one lies in
its correct combination with the other (Barret et al, 2008; Williams et al, 2010).
Practical aspects in delivering CBTMost CBT treatment manuals for OCD recommend twelve to twentyfive sessions. The manuals usually suggest that therapists use the first one or two
sessions to collect detailed information about the patient’s symptoms, how thepatient and the family deal with them, family environment, school performanceand other relevant issues on the patient’s functioning. As much psychoeducationas possible is also to be provided; this will involve detailed information about all

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Click on the picture to view adescription of the UCLA OCD
program (03:50)

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IACAPAP Textbook of Child and Adolescent Mental Healthaspects of the illness, including possible clinical symptoms, impact of comorbidity,
treatment options, duration of illness and duration of treatment, the risks of family
accommodation and how best to deal with a family member with OCD. Usually,
a 50 minute CBT session includes a review of the goals, review of the previous
week, provision of new information, therapist-assisted practice, homework for the
coming week, and monitoring (Steketee, 1999).
The success of CBT depends on understanding the illness, the basis for thetherapeutic activities and the cognitive processes implicated in the maintenance ofthe disorder. Clinical trials have shown that CBT has better outcomes when thepeople closest to the patient (parents, family members and teachers) are involvedin treatment (Piacentini & Langley, 2004; Freeman et al, 2008). Family members
may respond to the patient’s symptoms by facilitating avoidance, assisting on
ritualistic behaviors, or inadvertently participating in rituals (Calvocoressi etal, 1999; Barret et al, 2004; Freeman et al, 2008) described by some as family
accommodation (Calvocoressi et al, 1999). High levels of family accommodation
have been associated with symptom maintenance and poor outcome (Calvocoressi
et al, 1999; Amir et al, 2000). Thus, parents must be included in the treatment(Freeman et al, 2008); in fact, parents often become co-therapists and administer
treatment at home.
Pharmacological treatment
For greatest efficacy, the combination of CBT with medication has beensuggested as the treatment of choice for moderate and severe OCD (AACAP,2012). The Pediatric OCD Treatment Study (POTS), a 5-year, 3-site outcome
study designed to compare placebo, sertraline, CBT, and combined CBT withsertraline, concluded that the combined treatment (CBT+sertraline) was more
effective than CBT or sertraline alone. The effect sizes for the combined treatment,
CBT alone and sertraline alone were 1.4, 0.97and 0.67, respectively (Pediatric
OCD Treatment Study, 2004). Remission rates for SSRIs alone are less than one
third (Pediatric OCD Treatment Study, 2004; Franklin et al, 2011).
Selective serotonin reuptake inhibitors (SSRIs) are the first-line medication
for OCD in children, adolescents and adults (AACAP, 2012). Clomipramine, aserotoninergic tricyclic agent, was the first medication proven to be effective inthe treatment of OCD. Despite its efficacy (effect size: 0.85, confidence interval
0.32–1.39) (Watson & Rees, 2008), side effects – gastrointestinal, autonomic,
Table F.3.6
Medications effective for the treatment of pediatric obsessive-compulsive
disorder (adapted from Rosario et al, 2008).
Medication

FDA approved
for OCDin children

Minimumage (FDA)

Starting
dose (mg/day)

Maximum
dose (mg/day)

ClomipramineYes5

12.5 to 25

300

FluoxetineYes

82,5 to1080

SertralineYes

6

12,5 to 25

200

FluvoxamineYes

8

12,5 to 50

300

ParoxetineYes

82,5 to 10

60

Citalopram

No

N/A

2,5 to 10

60

Escitalopram

No

N/A

2,5 to1030

N/A: not applicable.

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IACAPAP Textbook of Child and Adolescent Mental Healthhepatic and, particularly, cardiac conduction problems – limit the clinical use ofclomipramine, especially in children and adolescents. For instance, prescribing
clomipramine requires electrocardiographic evaluation at baseline and follow up(Mancuso et al, 2010; AACAP, 2012).
Well-designed clinical trials have demonstrated the efficacy and safety of
the SSRIs fluoxetine, sertraline and fluvoxamine (alone or combined with CBT) in
children and adolescents with OCD. Other SSRIs such as paroxetine, citalopram
and escitalopram have also demonstrated efficacy in children and adolescents with
OCD, even though the FDA has not yet approved pediatric use (Rosario et al,2008; AACAP, 2012). A meta-analysis of all published randomized controlled
trials in children and adolescents with OCD found an effect size of 0.46 (95%
CI 0.37– 0.55) and showed a statistically significant difference between drug andplacebo (Geller et al, 2003).
Treatment should start with a low dose to reduce the risk of adverse effects.
An adequate trial should use the medication for at 10 to 16 weeks at adequate
doses (Table F.3.6). The optimal duration of treatment for children with OCD
is unknown. Most experts suggest that treatment should continue for at least 12
months after symptom resolution or stabilization, followed by a very gradualcessation (Rosario et al, 2008; Mancuso et al, 2010).
Non-responders
Despite the effectiveness of SSRIs, about half of the patients do notrespond or have significant residual symptoms, even with adequate duration oftreatment and maximum recommended or tolerated dosages. For these patients,
some strategies have been suggested and are described below. Unfortunately, there
are no systematic studies that compare switching medications with adding an
augmenting agent to the initial medication (AACAP, 2012).
•

The first strategy is to change to another SSRI.

•

In adults with partial response to SSRI, antipsychotics (Bloch et al, 2006) andclomipramine (Figueroa et al, 1998) have been used as augmentation agents.
Further investigation of these pharmacological interventions in children isnecessary. Antipsychotics may be indicated in the presence of tic disorders
or poor insight (Bloch et al, 2006). Clinical trials suggest that haloperidol(Mancuso et al, 2010), risperidone (Thomsen, 2004) and quetiapine (Cohenet al, 2003) can be effective. Olanzapine should be avoided in children due
to limited safety and the risk for metabolic syndrome (Rosario et al, 2008).
Concerns about neuroleptic augmentation include potential side effects suchas sedation, dysphoria, weight gain, and extrapyramidal symptoms. Novelaugmentation clinical trials have been reported for stimulants, gabapentin,
sumatriptan, pindolol, inositol, opiates, St. John’s wort, N-acetyl cysteine,memantine and riluzole, but further evidence is required before recommending
their routine use (AACAP, 2012).

•

Another strategy is to ascertain the presence of comorbid disorders (such as
ADHD, tics, depression or conduct disorder). The presence of comorbid
disorders has been associated with more severe symptoms and higher parental
stress, and may have a worse response to treatment (Grados et al, 2008; Storch
et al, 2008). In the presence of such conditions clinicians should consider
treating them in parallel (AACAP, 2012)•

Combining medication with CBT should always be considered. Franklin et al(2011) investigated whether CBT would augment antidepressant treatment inchildren who had responded only partially to medication. The study involved
124 participants with OCD aged 7 to 17 years randomized to medication alone

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Click on the picture to hear
Eli R Lebowitz PhD talkabout “creating effective
exposures” in the treatmentof childhood anxiety
disorders (14:21)

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IACAPAP Textbook of Child and Adolescent Mental Health

The mother brought J, 9 years of age, because his teacher was concerned about his spending too much time doing
exercises due to his concern that they had to be perfect. Also, J was leaving the classroom to wash his hands very often. His
mother had also noticed the same at home.
J’s was born after a lengthy delivery and showed moderated jaundice. J’s father had been diagnosed with Tourette’s
syndrome during childhood, but had been free from symptoms for many years.
During the assessment interview J said he felt “itching” in his hands, which forced him to wash them repeatedly. He also
said it took him a long time to do his homework because he needed to write and re-write everything until he felt that his
handwriting was just right. J did not complain about his symptoms and did not avoid washing his hands although he spent
about 2 hours a day doing it. He did not describe obsessive thoughts. When asked why he had to wash his hands or re-write
things he said that he just had to do it. J does not have tics, in the past or currently.
Scores on the CYBOCS were 17 (zero for obsessions; 17 for compulsions). On the DYBOCS symptom dimensions, scores
were zero for aggression, zero for sexual/religion, zero for hoarding, 12 for symmetry/ordering and 10 for contamination/cleaning. The total severity score was 12 and impairment 10, with a global DYBOCS severity score of 22 (moderate).
J and his family were referred to a twice a week CBT program, with sessions lasting 60 minutes. The therapist noticed thatparents were extremely worried about J’s future and whether or not he would succeed in school. After 12 sessions (six weeks)
J showed some improvement in symptoms but parents remained very anxious. For instance, even though J was spending lesstime doing his homework, his mother decided to help him daily and was practically doing the homework for him. The therapist
decided to continue with CBT but only once a week and parents started to participate in the sessions. After 16 weeks (22sessions), the CYBOCS score had decreased to 8 and the global DYBOCS score to 11, which meant symptoms remission.
Parents were also confident on J’s school abilities.
Comment
This vignette illustrates a patient with OCD of moderate severity in symmetry/ordering and washing/contamination symptom
dimensions. Symptoms were time consuming and compromised school performance. J had little insight about his symptoms.
Even though J did not report obsessions, he showed sensory phenomena, both physical (“itching”) and mental (perfectionism
and “just right” feelings). Family history of Tourette’s syndrome, birth trauma and jaundice increased vulnerability to OCD.
Parents were very anxious and had a high score on the family accommodation scale.
Considering that symptoms were moderate and there were no comorbid disorders, the initial treatment recommendation
was CBT. Fortunately, J. had access to professionals trained in CBT and the family agreed to this plan of action. Because
OCD waxes and wanes and is potentially chronic, less intense maintenance CBT is advisable.

(SSRI), medication plus conventional CBT (apart from medication management
visits a CBT protocol was administered by a psychologist consisting of 14 onehour sessions over 12 weeks involving psychoeducation, cognitive training,hierarchies of feared situations from least to most anxiety provoking to guide
exposure treatment, exposure and response prevention) or medication plus
instruction in CBT (a pharmacotherapist assigned to manage medication also
provided instruction in CBT procedures that were administered according toprotocol – 7 sessions over 12 weeks – with an average duration of 45 minutes;
instructions included psychoeducation, establishing a simple symptom severity
hierarchy, exposure and response prevention targets, and assigning homework).
Two brief telephone check-ins were also conducted to provide guidance about
CBT implementation at home. After 12 weeks of treatment 68.6% in the
medication plus conventional CBT group were considered responders comparedwith 34.0% in the medication plus instruction in CBT group, and 30.0% in
the medication alone group. That is, 14 CBT sessions delivered by a trained
expert added to medication doubled the response rate while a less intense CBTtreatment by a non-expert did not increased effectiveness over medication
alone (Pediatric OCD Treatment Study, 2004; Franklin et al, 2011)
Beyond the search for new treatment strategies, identification of people
at-risk of developing OCD is required in order to develop preventive strategies.
Several genetic, familial, individual and environmental risk factors have been
described (Table F.3.4). Apart from general measures to enhance mental health,currently there are no prevention programs of demonstrated effectiveness.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table F.3.7

Summary of recommendations for the treatment of OCD

TYPE

RECOMMENDED TREATMENT

Mild (CYBOCS
score: 16-19*)•

CBT alone (single or group, minimum 10 sessions)

Moderate (CYBOCS
score: 20-29*)•

CBT alone or combined with an SSRI (minimum 10week trial)

Severe (CYBOCS
score: 30-40*)•

CBT+SSRI (minimum 10-week trial)

Remission (CYBOCS
total score less than
10)•

Maintenance CBT (booster sessions for a minimum of
12 months)•

Maintenance of SSRI at an optimal dose for a minimumof 12 months

Partial response(35% to 50%
decrease in
CYBOCS score after
achieving the optimal
tolerated dose of
SSRI for a minimumof 10 weeks)•

Switch to another SSRI•

Augment with CBT (if not administered already)•Augment with atypical antipsychotic (E.g. risperidone,
quetiapine, aripiprazole or haloperidol)•

Augment with clomipramine (ECG monitoring)

Non-response (lessthan 35% symptom
remission)•

Review diagnosis, comorbidities, compliance andfamily accommodation•

Switch to another SSRI•

Augment with CBT (if not administered already)•Augment with atypical antipsychotic (e.g., risperidone,
quetiapine, aripiprazole or haloperidol)•

Augment with clomipramine (ECG monitoring)•

Treat comorbid disorders concurrently* March & Mulle (1998) severity criteria. CBT: cognitive behavior treatment provided by acompetent clinician trained in this form of treatment in sessions lasting at least 60 minutes;
CYBOCS: Children's Yale-Brown Obsessive Compulsive Scale scores, SSRI: selective
serotonin reuptake inhibitor.

SUPPORT GROUPS AND ASSOCIATIONSWhen people are told they have a family member with OCD, they usually
benefit from support groups to deal with it, particularly when the sufferer is achild or adolescent. Participating in a support group is helpful in handling thestress of raising a child with OCD. Support groups, that often have mental healthprofessionals as advisers, meet regularly and seek to educate about the disorder,
help people to recognize symptoms, reduce family accommodation, and find theright treatment. Getting together with people who face the same problems gives anopportunity to exchange experiences, discuss how others handle the symptoms andlearn more about the disorder. Support groups can also be helpful for the patients,
although less so in the case of children. A list of patient and family associations inseveral countries can be found at http://www.geonius.com/ocd/organizations.html

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IACAPAP Textbook of Child and Adolescent Mental Health

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