OCD in Children and Adolescents

Pediatric OCD: Core Concepts - Tiny Worries, Big Impact

• Prevalence: Affects ~1-2% of children and adolescents.
• Age of Onset: Bimodal peaks at 7-8 years and early adolescence.
• Gender Ratio: Boys > Girls in childhood; ratio evens out in adolescence.
• Common Obsessional Themes:
  • Contamination (germs, dirt)
  • Harm (to self or others)
  • Symmetry, ordering, exactness
  • Scrupulosity (religious/moral)
• Impact: Causes significant distress, impairs academic/social development, and strains family functioning.

⭐ PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) can cause sudden, severe OCD onset post-strep infection.

Spotting OCD: Signs & Symptoms - Little Rituals, Loud Alarms

• Common Obsessions (Intrusive Thoughts/Images):
  • Contamination (germs, dirt)
  • Harm (to self/others)
  • Scrupulosity (religious/moral worries)
  • Sexual thoughts (unwanted)
  • Symmetry/Exactness needs
• Common Compulsions (Repetitive Behaviors/Mental Acts):
  • Washing/Cleaning
  • Checking (locks, homework)
  • Repeating (actions, phrases)
  • Ordering/Arranging
  • Mental compulsions (counting, praying)
• Key Differences from Adult OCD:
  • ↓ Insight (may not see rituals as excessive)
  • ↑ Magical thinking (vs. adults)
  • Ego-syntonic initially (rituals feel "right," less initial distress)
  • ↑ Family involvement/accommodation (parents may enable rituals)

⭐ Family accommodation of rituals is common in pediatric OCD and can inadvertently maintain symptoms, often becoming a target for intervention.

Diagnosing Kiddie OCD: The Full Picture - Puzzle Pieces Together

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Treating Young Minds: Meds & More - Gentle Steps, Strong Support

• Core: Cognitive Behavioral Therapy (CBT) with Exposure & Response Prevention (ERP) is first-line; family involvement crucial.
• Meds: SSRIs for moderate-severe or CBT-refractory OCD.
  • Fluoxetine: Start 5-10mg, target 20-60mg/day. (FDA approved)
  • Sertraline: Start 25mg, target 50-200mg/day. (FDA approved)
  • Fluvoxamine: Start 25mg, target 50-200mg/day (up to 300mg). (FDA approved)
  • Paroxetine: Also used.
  • Titrate slowly; continue ≥12 months post-remission.
• Boost: Augment with low-dose risperidone for partial/no SSRI response.
• ⚠️ Watch: SSRI side effects (GI, sleep); ↑ suicidality risk (<25 yrs) - Black Box Warning.

⭐ Fluoxetine, Sertraline, and Fluvoxamine are the SSRIs with FDA approval for pediatric OCD.

Course & Comorbidities: The Long Haul - Navigating Rough Waters

• Course: Often chronic; waxing/waning symptoms.
• Prognosis: Worse with early onset, severity, family accommodation, comorbidities.
• Common Comorbidities:
  • Anxiety (SAD, GAD), ADHD, Tics (Tourette's), Depression, Disruptive behavior.
  • ⭐ > Tic disorders (e.g., Tourette's) co-occur in ~30-50% of pediatric OCD cases.
• Impact: Affects academic, social, family life.

High‑Yield Points - ⚡ Biggest Takeaways

• Early onset is common (mean ~10 yrs), with boys often presenting earlier; family-related themes are frequent in obsessions.
• Family accommodation of rituals is a significant factor that can maintain symptoms and impact treatment.
• High rates of comorbidity, especially with ADHD, anxiety disorders, and tic disorders (particularly Tourette syndrome in boys).
• Cognitive Behavioral Therapy (CBT), specifically Exposure and Response Prevention (ERP), is the first-line treatment.
• SSRIs (e.g., fluoxetine, sertraline, fluvoxamine) are the first-line pharmacotherapy; clomipramine is a potent second-line option.
• Consider PANDAS/PANS in cases of acute, dramatic onset of OCD symptoms following an infection (e.g., streptococcal).