Obsessive compulsive disorder in children and adolescents

Introduction

OCD can cause problems in many areas of life, including school, home, and social life. But with treatment, most people with OCD can live happy and productive lives.

CONCLUSION

Aetiology

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Genetic factors play a major role in the development of paediatric OCD, with studies suggesting that they explain 45%–65% of the variance.

Genes within the serotonergic, dopaminergic and glutamatergic system appear to be involved.

Neuropsychological models suggest that OCD arises from alterations to frontostriatal circuitry, specifically hyperactivation of the orbitofrontal cortex.

Environmental factors also play a role, but less is known about their effects. Some studies have found associations between social isolation, physical abuse, and negative emotionality with an increased risk of OCD.

A subgroup of children experience sudden onset OCD and/or tics after streptococcal infection. This is known as PANDAS/PANS. The exact mechanism is unknown, but there is some evidence that immune and infectious factors may be involved.

Diagnostic criteria and classification

  1. Either obsessions or compulsions or both present on most days for a period of 2 weeks
  2. Obsessions and compulsions as:
    *Patient is aware its originated from their own mind
    *They are repetitive, unpleasant and distressing to the 
      patient. At least one is perceived as excessive or 
  unreasonable (Ego dystonic)
    *At least one is resisted unsuccessfully even though other 
     may be present that the sufferer no longer resists.
    3.The symptoms must be disabling.Even young children will have some insight into senseless of thought and behavior

Asessment and diagnosis

1.Early diagnosis

Challenges may face*

Embarrassment and concealment: Young people with OCD may hide their symptoms due to shame or fear of judgment.

Lack of insight: They may not recognize their behaviors as unusual or excessive.

Difficulty differentiating: Normal developmental rituals can be mistaken for OCD symptoms.

Heterogeneity: OCD symptoms vary greatly between individuals, making diagnosis complex.

2.screening and diagnosis

eg:.Short OCD Screener

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Do you wash or clean a lot?

Do you check things a lot?

Is there any thought that keeps bothering you that you would like to get rid of but cannot?

Do your daily activities take a long time to finish? (eg, getting ready for school)

Are you concerned about putting things in a special order or are you very upset by mess?

Do these problems trouble you?

Treatment

Differential diagnosis

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Differentiating from Autism Spectrum Disorder (ASD): Look for obsessions, anxiety relief from compulsions, and egodystonic (unwanted) behavior to distinguish from ASD-related stereotyped behaviors.

Differentiating from tic disorders: Check for intentionality, complexity (compulsions are more elaborate), and anxiety relief in OCD compared to involuntary and simpler tics.

Differentiating from psychosis: Consider insight into irrationality, presence of other OCD symptoms, and absence of other psychotic features like hallucinations.

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Short OCD Screener (SOCS): This questionnaire is effective in identifying most cases.

Further assessment: If positive on SOCS, detailed history, developmental history, and separate interview are crucial.

Separate interview: This allows young people to disclose sensitive thoughts and feelings privatel

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Prevalence of OCD is elevated in individuals with ASD.

OCD treatments are effective in children with tics and OCD.

Transformation obsessions and aggressive obsessions can be mistaken for delusions.

Comorbidity with ASD and tic disorders is common

CBT

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Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (E/RP):

Considered the first-line treatment for mild to moderate cases.

Short-term, typically 12-20 weekly sessions.

Involves gradually confronting feared situations and resisting compulsions.

Effective for children as young as 3 years old.

40%-65% reduction in symptoms, with gains maintained up to 18 months.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Considered for severe cases or if CBT fails.

Range of SSRIs effective, including fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram.

29%-44% reduction in symptoms, well-tolerated and safe.

In the UK, only sertraline and fluvoxamine are licensed for children.

Treatment -Resistant OCD

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A significant proportion of young people with OCD don't respond well to standard treatments like CBT and SSRIs.

Even when treatment shows some improvement, residual symptoms can remain.

Understanding why some individuals are treatment-resistant is a complex issue

Comorbid conditions can play a role, with some affecting response more than others.
Tics, externalizing disorders, and ASD may require modified treatment approaches.

Treatment option of treatment resistant OCD

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Trying different SSRI medications or clomipramine (tricyclic drug).

Augmenting SSRI with a low dose of a dopamine antagonist (mixed evidence).

High-quality exposure-based CBT is generally preferred over risperidone augmentation.

Questions

uestion

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What are the specific modified treatment approaches for different comorbidities?

What are the risks and benefits of using dopamine antagonists to augment SSRI treatment?

What are the emerging treatment options for treatment-resistant OCD?

Where can I find resources for young people and families struggling with OCD?

OCD commonly starts in childhood.
It can persist into adult life.In addition to causing significant distress and impairment in children, it can persist into adult life

There are national guidelines for treating OCD in children.
CBT is an effective treatment for OCD in children and adolescents.