Obsessive-Compulsive Disorder in Youth: Assessment and Treatment

J​ennifer G. Wells, MSW, LISW

Lindner Center of HOPE and Lindner Center Professional Associates, Mason, Ohio, and the Department of Psychiatry, University of Cincinnati and University of Cincinnati Physicians, Cincinnati, Ohio

Of people who develop OCD, 25% will have it before they turn 15 years old and half will have it by age 19 years.1 Therefore, OCD needs to be recognized and treated in youths. Clinicians may need to assess for infectious triggers and should adapt treatment to the child’s developmental level and other needs.

Assessing and Treating Pediatric OCD

According to the diagnostic criteria2 for OCD, a person must have obsessions, compulsions, or both, as described below.

  1. Obsessions are intrusive, unwanted, recurrent, persistent thoughts that usually cause anxiety or distress, and the person tries to ignore them or neutralize them with another thought or by performing an action (ie, compulsion)
  2. Compulsions are repetitive behaviors or mental acts that the individual feels must be performed according to rigid rules to reduce anxiety or distress or prevent a dreaded situation
    Note: Young children may not be able to articulate the purpose of the compulsions
  3. The obsessions or compulsions are time-consuming or cause impairment or great distress, and they cannot be attributed to another condition or to substances

AV 1. First-Line Treatment of OCD (00:35)

Based on Guidelines 1A and 2A of Expert Consensus Guidelines5
Abbreviations are defined before the References

The results of the Pediatric OCD Treatment Study II (POTS II)3 support the growing evidence base4 that encourages the use of ERP (a form of behavioral therapy) as an initial or augmenting therapy for patients of all ages with OCD. According to the Expert Consensus Guidelines,5 ERP should be the first line of treatment for prepubertal patients (AV 1).

Numerous factors can complicate the treatment of children with OCD, including developmental factors, family accommodation, and comorbidities.

Developmental factors and insight. Because children may have low insight into their illness, clinicians must educate them about OCD to help them recognize their need for treatment. To make education developmentally appropriate for pediatric patients, clinicians might use stories and metaphors.6 An intervention that may help children understand and “depersonalize” their OCD (ie, see it as something separate from themselves that they can overcome) involves having them create a nickname for the illness.7

Before children start ERP, they should create a list of thoughts or situations that create anxiety and provoke avoidance or rituals, and then rank the level of distress each causes if the compulsions are not performed; this list is called a fear hierarchy or fear thermometer.8 By first treating ERP targets from the lower end of their fear thermometer, children can see improvement as their lesser fears diminish with treatment, and they can work up the hierarchy.6 Rewarding the child’s efforts (verbally or with small prizes or certificates) is also helpful.8

Family involvement. Clinicians should collaborate with and support family members to assist them in setting and maintaining appropriate behavioral limits for the pediatric patient. Sometimes, family members become intertwined in the child’s compulsions and resist change because of the child’s resistance to eliminating the compulsions. If family members understand the detrimental effects of untreated compulsions, they will be more likely to stop accommodating them. Research9 has shown that family accommodation of the child’s OCD mediates the relationship between symptom severity and functional impairment. Conversely, the family should not push children to move up the fear hierarchy too fast.6 Families should be coached to systematically withdraw from compulsions based on the child’s hierarchy distress level rather than the negative impact of the compulsion on the family.

Comorbid conditions. Pediatric OCD is often comorbid with other anxiety disorders, ADHD, Tourette’s disorder or tics, and autism spectrum disorders.10,11 Addressing comorbidity in pediatric patients with OCD should follow similar guidelines as with adults. Children over the age of 9 years with Tourette’s disorder may benefit from Comprehensive Behavioral Intervention for Tics (CBIT), which utilizes habit reversal training.12

AV 2. Triggers of Acute-Onset OCD in Youth (00:29)

Based on Swedo et al13
Abbreviations are defined before the References

Assessing and Treating PANS

PANS refers to Pediatric Acute-onset Neuropsychiatric Syndrome (AV 2).13 This syndrome, which includes a form known as PANDAS, encompasses an array of symptoms including but not limited to those of OCD. Criteria were developed for PANDAS14 in 1998 and expanded for PANS13 by the NIH in 2010; PANS criteria include the following:

  1. Abrupt, dramatic onset of OCD or severely restricted food intake
  2. Concurrent presence of at least 2 of the following symptoms, with sudden onset and great severity:
    • Anxiety
    • Emotional lability and/or depression
    • Irritability, aggression, and/or oppositional behaviors
    • Behavioral or developmental regression
    • Deterioration of school performance
    • Sensory or motor abnormalities
    • Somatic disturbances such as sleep or urinary disturbance
  3. Symptoms cannot be better explained by a known neurologic or medical disorder

Anxiety symptoms may include terror-stricken look (mydriasis) and separation anxiety, while sensory and motor abnormalities include hallucinations and tics.13 Sleep problems, such as nightmares and insomnia, and urinary problems (frequency or enuresis) are common. The symptoms of PANS are so overwhelming that children cannot hide them at school or in other social situations.

A temporal relationship exists between an infectious trigger and symptom exacerbation.15 A lag occurs only between the initial infection and first onset of symptoms. PANS may be triggered by streptococcus infection (ie, PANDAS) and by nonstreptococcus organisms such as mononucleosis, mycoplasma, or Lyme disease as well as by noninfectious factors.

Although more research is needed to provide evidence-based recommendations, PANS assessment may include the following steps.15 To detect strep bacteria in the throat, 2 vigorous throat swabs may be necessary, and if the rapid antigen detection test is negative, a back-up throat culture is needed.16 Medical evaluation to detect occult infections (in adenoids and tonsils, urethra, or anus) is appropriate if the throat culture is negative.15 The presence of choreatic movements may indicate Sydenham chorea (another poststreptococcal disorder) rather than PANS, which is associated with finer choreiform finger movements.13 Strep titers can collect helpful information but do not confirm or rule out PANDAS. Referral to a pediatric immunologist may be helpful.

More

Treatment with antibiotics may be needed if an occult infection is detected. Usual antibiotic treatment for strep throat is up to 10 days,16 but a longer duration may be necessary to eradicate an occult infection.15 Some researchers17 have suggested that, after initial treatment, antibiotics may be continued to prevent strep and reduce neuropsychiatric exacerbations, but further research with larger sample sizes is needed.15 Adding probiotics at a different time of day than the antibiotics should be considered.

Standard treatments for OCD should be used, but both ERP and medication dosing should proceed at a slower pace than in patients with typical OCD.15

Immune-based therapies can be used for PANDAS and many cases of PANS15; these include NSAIDs (aspirin, ibuprofen, and naproxen), steroids, IVIG, and plasma exchange. Practice guidelines16 for managing strep recommend avoiding aspirin in children. Acetaminophen and NSAIDs are recommended if needed as adjunctive treatment with antibiotics, but corticosteroids are not recommended.15,16 In children with PANDAS, IVIG and plasma exchange have shown efficacy in OCD symptom reduction.18

Psychosocial rehabilitation may also be needed to recover lost ground during the child’s illness. Children and parents may both need supportive therapy.13

Conclusion

Pediatric OCD is a highly treatable condition using ERP, as well as adjunctive medication for adolescents with moderate to severe OCD. Children may have little insight into their obsessions and compulsions, so clinicians may have to help them recognize their disorder and prepare for treatment. Working through a fear hierarchy list and receiving rewards can help motivate children as they improve. Clinicians should involve family members and diagnose comorbid conditions to increase treatment success in pediatric patients. If the onset of OCD is sudden, clinicians should consider a diagnosis of PANS and provide appropriate tests and treatment using the most relevant guidelines and latest research.

Clinical Points

  • Use ERP as first-line treatment for prepubertal and adolescent patients with OCD, and add an SRI if an adolescent has severe OCD
  • Tailor treatment by considering insight and developmental level, involving family members, and diagnosing comorbid conditions
  • Consider a diagnosis of PANS if the onset of pediatric OCD is sudden

Abbreviations

ADHD = attention-deficit/hyperactivity disorder, CBT = cognitive-behavioral therapy, DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, ERP = exposure and response/ritual prevention, IVIG = intravenous immunoglobulin, OCD = obsessive-compulsive disorder, NIH = National Institutes of Health, NSAID = nonsteroidal anti-inflammatory drug, PANS = pediatric acute-onset neuropsychiatric syndrome, PANDAS = pediatric autoimmune neuropsychiatric disorders associated with streptococcus, SRI = serotonin reuptake inhibitor, YBOCS = Yale-Brown Obsessive-Compulsive Scale

Take the online posttest.

References

  1. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602. PubMed
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
  3. Franklin ME, Sapyta J, Freeman JB, et al. Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the Pediatric OCD Treatment Study II (POTS II) randomized controlled trial. JAMA. 2011;306(11):1224–1232. PubMed
  4. Freeman J, Garcia A, Frank H, et al. Evidence-base update for psychosocial treatments for pediatric obsessive-compulsive disorder [published online ahead of print June 9, 2013]. J Clin Child Adolesc Psychol. PubMed
  5. March JS, Frances A, Carpenter D, et al. The Expert Consensus Guideline Series: Treatment of obsessive-compulsive disorder. J Clin Psychiatry. 1997;58(suppl 4):1–72.
  6. Lewin AB, Storch EA, Geffken GR, et al. A neuropsychiatric review of pediatric obsessive-compulsive disorder: etiology and efficacious treatments. Neuropsychiatr Dis Treat. 2006;2(1):21–31. PubMed
  7. March JS. Talking Back to OCD: The Program That Helps Kids and Teens Say "No Way” and Parents Say “Way to Go." New York, NY: The Guilford Press; 2007.
  8. March JS, Mulle K. OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual. New York, NY: The Guilford Press; 1998.
  9. Bipeta R, Yerramilli SS, Pingali S, et al. A cross-sectional study of insight and family accommodation in pediatric obsessive-compulsive disorder. Child Adolesc Psychiatry Ment Health. 2013;7(1):20. PubMed
  10. Coskun M, Zoroglu S, Ozturk M. Phenomenology, psychiatric comorbidity and family history in referred preschool children with obsessive-compulsive disorder. Child Adolesc Psychiatry Ment Health. 2012;6(1):36. PubMed
  11. van Steensel FJ, Bögels SM, Perrin S. Anxiety disorders in children and adolescents with autistic spectrum disorders: a meta-analysis. Clin Child Fam Psychol Rev. 2011;14(3):302–317. PubMed
  12. Piacentini J, Woods DW, Scahill L, et al. Behavior therapy for children with Tourette disorder: a randomized controlled trial. JAMA. 2010;303(19):1929–1937. PubMed
  13. Swedo SE, Leckman JF, Rose NR. From research subgroup to clinical syndrome: modifying the PANDAS criteria to describe PANS (pediatric acute-onset neuropsychiatric syndrome). Pediatr Therapeut. 2012;2(2):doi:10.4172/2161-0665.1000113. Full Text
  14. Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1998;155(2):264–271. PubMed
  15. NIMH Intramural Research Program, Pediatrics and Developmental Neuroscience Branch. Information About PANDAS. Published March 12, 2012. http://intramural.nimh.nih.gov/pdn/web.htm. Accessed August 16, 2013.
  16. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):1279–1282. PubMed
  17. Snider LA, Lougee L, Slattery M, et al. Antibiotic prophylaxis with azithromycin or penicillin for childhood-onset neuropsychiatric disorders. Biol Psychiatry. 2005;57(7):788–792. PubMed
  18. Perlmutter SJ, Leitman SF, Garvey MA, et al. Therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood. Lancet. 1999;354(9185):1153–1158. PubMed
​​