Owen, an 8-year-old boy, is brought to his pediatrician by his mother. She has noticed that Owen is spending increasing amounts of time doing some repetitive behaviors such as counting to himself and needing to tap particular objects a specified number of times. Certain numbers seem to have special significance, and Owen has expressed some vague concern that something bad could happen if he does not do these behaviors. The rituals are starting to impact his schoolwork, as he often can get "stuck" during assignments. The mother is aware that many kids have some superstitions and wants to know if this is "something more."
Obsessive-compulsive disorder (OCD) is a relatively common condition that can respond quite well to treatment. This case example outlines an approach that pediatricians can take to its diagnosis and management in a primary care setting.
The diagnosis of OCD, according to DSM-5, requires the presence of distressing or impairing obsessions or compulsions. The definition didn’t change much from DSM-IV. Obsessions in children can revolve around things like contamination, disturbing thoughts of harm coming to others, sexual thoughts, or special numbers or words. Compulsions can include rituals with washing, checking, counting, arranging, and hoarding, among other behaviors.
When beginning to evaluate for possible OCD, it is important to talk to both the child and the parent, as it is common for parents to be unaware of the extent of the problem. An instrument called the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) is considered to be the standard in the quantitative assessment of OCD. The rating scale and checklist are easy to administer and appear to be in the public domain.
While the diagnosis is often fairly straightforward, it does take some time, and pediatricians should feel comfortable with the idea of not trying to do everything in one visit. Instead, consider scheduling another visit or two to obtain more time to do a careful assessment. During this evaluation, a couple questions are good to keep in mind.
1. Was a diagnosis of an autistic spectrum disorder missed? OCD behaviors are extremely common among children with autistic spectrum disorders. It might be worthwhile to make sure that the developmental history (pointing, babbling, social smile, odd mannerisms) doesn’t suggest the possibility of autism.
2. Could this be a case of a PANS? There remains discussion about the possibility of an autoimmune origin to some children with OCD. The previous term of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS) has been changed to Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) to reflect a broader profile of behaviors and possible infectious triggers. While the idea remains debated in some circles, there may be value in making sure that there is not an infection lurking that should be treated.
When querying about particular OCD symptoms, go through a list with a patient (such as provided on the CY-BOCS), and don’t rely on self-disclosure, as some symptoms, such as seeing violent or sexual images, can be quite disturbing to the child, who often won’t bring them up on his or her own.
The recommended first-line treatment for OCD is a type of cognitive-behavioral therapy called exposure and response prevention (ERP). It is a structured form of therapy that involves patients unlearning the association that rituals are necessary in order for their fears not to be realized. While effective, the challenge is often finding a therapist with this type of training.
In many cases, it is reasonable to wait on medication treatment until after a course of ERP has been tried. For more severe cases, it is also reasonable to use both psychotherapy and medications at the same time. Some patients will say that the medication helps them do the work required in therapy.
When it comes to medications, there are a number of selective serotonin reuptake inhibitors (SSRIs) that have shown to be effective and have Food and Drug Administration approvals for pediatric OCD (for some reason that escapes me, many pharmaceutical companies have sought FDA approval for OCD and not other child psychiatric disorders). Fluoxetine, sertraline, and fluvoxamine all have FDA approval, in addition to the tricyclic clomipramine for use in refractory cases. As in all children, starting at a low dose is usually prudent (5-10 mg of fluoxetine, 12.5-25 mg of sertraline), but with OCD higher doses are often required for maximal response (more than 100 mg of sertraline or 40 mg of fluoxetine, depending on the patient’s age, size, and tolerance). It is also important to remember that the suicide warning present for the SSRIs also applies to children with anxiety disorders.