Max is an 8-year-old boy in the third grade, and you have been his pediatrician since birth. Described as “emotional” and “particular” since his early years, Max is prone to prolonged tantrums that have not improved with age. Parents have described a tic that involves repeatedly touching his ear, but this has not been observed in the office setting. Max has struggled with some attention issues at school, and often needs help finishing assignments. The family is feeling increasingly desperate for ways to manage his near-daily meltdowns at home, and parenting strategies you’ve discussed thus far don’t seem to be helping much. Should obsessive-compulsive disorder be in your differential? And at what point do you seek outside evaluation?
miodrag ignjatovic/E+
OCD is a condition characterized by recurrent, intrusive, and unwanted thoughts, images, and urges (obsessions), and repetitive behaviors or mental acts performed in a particular way to reduce anxiety (compulsions). It affects 1%-3% of children, and onset can be as early as age 3-4 years. While the average age of onset in children is approximately 10 years old, average age of diagnosis is at least several years later.1 A primary care physician’s ability to recognize OCD symptoms in children, perform an initial assessment, and connect the child to appropriate clinical care is key to reducing the years of difficulty that children and families often endure prior to beginning treatment.
Dr. Haley McGowan
Common obsessions in children include contamination, fear of harm to self or others, symmetry, and the belief that bad things will occur if rituals are performed incorrectly. Common compulsions include checking, washing, ordering, and mental acts such as praying or counting to one’s self.1,2 In addition to the fact that OCD presentations are highly heterogeneous, early diagnosis is challenging due to significant overlap of OCD symptoms with developmentally normal behaviors. For example, magical or superstitious thinking is common among school-age children who avoid stepping on cracks or utilize lucky numbers. What differentiates OCD is the presence of obsessions and/or compulsions that are time consuming and cause subjective distress or functional impairment. Children often are adept at keeping OCD symptoms secret. At time of diagnosis, the child may have a complex array of discreet behaviors to manage distress and minimize shame. Children may not have insight into the irrationality of their thoughts or behaviors, but they are certainly aware of how terrible and confused they feel inside, and how it affects their relationship with their parents. Rituals, such as those that delay bedtime or cause school tardiness, may look like oppositional behaviors and cause immense frustration for parents.
Comorbidities are common and include ADHD, oppositional defiant disorder, depression, and Tourette syndrome.3 Nearly 60% of children with OCD meet criteria for a tic disorder at some point in their lifetime.4 Compulsions designed to ease a feeling of internal discomfort, such as touching or tapping, are particularly typical of patients with OCD and comorbid tics. Often these children will express a need for things to be “just right,” with lasting relief from such a feeling rarely found. While sensory intolerances are not part of OCD’s diagnostic criteria, clinical experiences and growing research point to a high prevalence in affected children.5,6 Sensory intolerances may even be the primary presenting problem. Examples include clothing feeling uncomfortable, or inability to tolerate certain smells or innocuous sounds.
The preferred method for assessment of OCD in children is the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS), a semi-structured, clinician-rated interview designed to elicit symptoms, severity, and distress. While time constraints may prevent use of the CY-BOCS in the primary care setting, a handful of screening questions instead can go a long way. These might include:
- Do you have to do things in a certain way, such as washing or making things “just right?”
- What happens if you can’t do things in a certain way?
- Do you have unwanted thoughts that keep coming back and are hard to get rid of?
Equally as important as understanding a child’s OCD symptoms is understanding how the family has, often unwittingly, become intertwined in a web of OCD-driven behaviors. In an effort to soothe the child, prevent emotional outbursts, or simply get through the day, parents may find themselves accommodating behaviors that seem irrational. Despite parents’ best intentions, this is likely reinforcing OCD patterns. Parents may be asked by the child to repeat a reassuring phrase in a certain way, arrange furniture “just so,” or drive a certain route to school. In the case of contamination fears, a child may be taking several showers per day, using two bottles of shampoo per week, and demanding that his or her clothes be washed separately before a parent begins to realize the cumulative impact of these unusual behaviors on the household. In addition to exploring concerns, primary care physicians can provide a sounding board for exhausted parents wondering if other families face the same thing. While connecting the family to treatment, they also can provide reassurances that treatment can dramatically shift the trajectory of the illness.
Treatment of pediatric OCD begins with a specific form of cognitive behavioral therapy (CBT) called Exposure and Response Prevention therapy (ERP). ERP requires a skilled therapist, and a strong alliance with a child and family because the child will be asked to gradually challenge compulsions head-on and tolerate the accompanied distress. CBT/ERP is associated with a 40%-65% reduction in symptoms, but combination with SSRI therapy improves outcomes in more severe cases.3 Despite limited mental health resources and long wait lists in many parts of the country, connection to OCD-specific treatment is increasingly feasible in virtual format via online support groups and telemedicine.
“Max” may experience any number of OCD-related symptoms that a primary care physician could deftly uncover. He may become “stuck” at school because his handwriting accidentally strayed below the line. He may have hours-long meltdowns because his hair never feels right. He may touch his ear to prevent tragic harm coming to his mother. Whatever further exploration reveals, Max and his family stand to benefit immensely from early detection and intervention.
Dr. McGowan is assistant professor of psychiatry and pediatrics at the Vermont Center for Children, Youth, and Families, University of Vermont Medical Center, Burlington. She had no relevant financial disclosures. Email Dr. McGowan at pdnews@mdedge.com.
Resources for providers and families*
UNSTUCK: An OCD Kids Movie. Featuring a 23-minute documentary film about children living with OCD, this website also is rich in OCD-related resources.
International OCD Foundation. Has information for families about OCD. Also has a resource directory for therapists, clinics, support groups, and other organizations specializing in OCD and related disorders in different geographic areas.
*Of note, both resources above include COVID-19-specific resources for those struggling with worsening OCD symptoms as a result of the pandemic.
References
1. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2020, pp. 518-27).
2. J Amer Acad Child Adol Psychiatry. 2012;51(1):98-113.
3. J Clin. Invest. 2009;119(4):737-46.
4. Arch Dis Child. 2015;100(5):495-9.