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Obsessive-compulsive Disorder in Children and Adolescents - Coggle Diagram
Obsessive-compulsive Disorder in Children and Adolescents
Definition
OCD is a psychiatric condition characterized by persistent, unwanted intrusive thoughts, images, and urges (obsessions), along with repetitive behaviors or mental acts (compulsions).
Aetiology
Genetic Factors in Pediatric OCD
Genetic factors explain 45%-65% of the variance, indicating higher heritability compared to most other anxiety disorders and depression in youth.
Twin, family, and segregation studies strongly support a genetic component in pediatric OCD.
Early-Onset OCD as a Developmental Subtype
Heritability of OCD is greater in pediatric cohorts compared to adults, suggesting early-onset OCD as a developmental subtype.
Polygenic Nature of Genetic Influence
Genome-wide association studies and meta-analyses indicate polygenic genetic influence on OCD, involving genes within the serotonergic, dopaminergic, and glutamatergic systems.
Neuropsychological Models
OCD is proposed to arise from alterations to frontostriatal circuitry, with hyperactivation of the orbitofrontal cortex mediating obsessions and compulsions.
Functional neuroimaging studies show increased activation in the orbitofrontal cortex in both children and adults with OCD.
PANS (Pediatric Acute-Onset Neuropsychiatric Syndrome)
Clinical evidence suggests a subgroup of children with sudden onset OCD and/or tics after streptococcal infection.
Termed PANS, these children may exhibit more widespread neuropsychiatric difficulties and uncertain etiology.
Therapeutic Approaches for PANS
Interest in therapies targeting immune and infectious causes, but effectiveness is inconsistent.
Assessment and Diagnosis
OCD is often undetected for many years before an accurate diagnosis is made, especially in young people.
a six-question screening tool called the Short OCD Screener (SOCS) has a high sensitivity of 97% in detecting OCD in pediatric cases.
The SOCS is not a diagnostic tool, but it can help identify potential cases, and further assessment, including a detailed history and a separate interview with the young person, is required.
Differential diagnosis
Autism spectrum disorders (ASDs) often include restricted interests and stereotyped behaviors, which may resemble OCD compulsions. However, true compulsions are typically preceded by obsessions, associated with anxiety relief, and egodystonic.
Comorbidity between OCD and tic disorders is common. Complex tics can be mistaken for compulsions, but they are typically involuntary, whereas compulsions are deliberate actions aimed at reducing anxiety.
Distinguishing between OCD and psychosis is important. OCD obsessions, even bizarre ones, usually involve some insight into their irrationality and are not part of a broader delusional set of beliefs. Other symptoms of OCD are present, while symptoms of psychosis like hallucinations and thought disorder are absent.
Treatment
Two established treatments for pediatric OCD are Cognitive Behavioral Therapy (CBT) incorporating exposure with response prevention (E/RP) and Selective Serotonin Reuptake Inhibitors (SSRIs).
CBT for pediatric OCD typically involves 12-20 weekly sessions focusing on E/RP, where the individual gradually confronts feared situations and refrains from compulsive behaviors.
Randomized controlled trials (RCTs) demonstrate that CBT leads to a 40%-65% reduction in symptoms, is effective even for children as young as 3 years old, and maintains gains up to 18 months post-treatment.
Combining CBT with SSRIs has shown superior outcomes compared to either treatment alone, with studies indicating that CBT enhances outcomes for individuals receiving SSRIs.
Treatment-Resistant OCD
Some young people with OCD do not respond to Cognitive Behavioral Therapy (CBT) or Selective Serotonin Reuptake Inhibitors (SSRIs), and many experience residual symptoms after treatment.
Children failing to respond to CBT and an initial SSRI should undergo additional trials of at least one other SSRI. Clomipramine, a non-SSRI, may be considered in resistant cases after multiple SSRI failures.
Exposure-based CBT is emphasized as a key treatment for children with OCD, while risperidone augmentation is considered a less favorable option based on recent research.
Future Direction
A significant challenge in treating young people with OCD is the limited access to quality Cognitive Behavioral Therapy (CBT) due to geographical barriers and a shortage of trained therapists.
Recent research has focused on developing evidence-based methods to increase the availability and accessibility of CBT, including delivery via telephone, web-camera, and internet-based CBT with minimal therapist input.
Pharmacological developments include the exploration of d-cycloserine (DCS) as a potential augmentation strategy for CBT in OCD.