Clinical Review: Obsessive compulsive disorder in children

Obsessive-compulsive disorder is an anxiety disorder

Developing a therapeutic relationship is crucial if change is to be made (iStock)
Developing a therapeutic relationship is crucial if change is to be made (iStock)

Section 1: Epidemiology and aetiology

Obsessive compulsive disorder (OCD) is a psychiatric disorder characterised by persistent and intrusive thoughts, images and urges (obsessions) and repetitive behaviours (compulsions), as listed in table 1.

The symptoms typically wax and wane, but often follow a chronic course, causing functional impairment and distress.

The estimated prevalence in children and adolescents is 0.25-4%. It was previously considered rare in children. Paediatric OCD is associated with an increased risk of other psychiatric disorders in adulthood. Causation is poorly understood but it can be bio-psychosocial and multifactorial.

Contributory factors

  •  Genetic: OCD is a highly heritable condition. First-degree relatives and monozygotic twin offspring of patients who have OCD have higher rates of OCD and anxiety disorders.
  •  Neurobiological: Characteristic neuropsychological profiles have been found in children and adults who are diagnosed with OCD.
  •  Environmental: The role of environmental factors remains unclear, with conflicting evidence regarding environmental triggers such as social isolation and physical abuse.
  •  Individual: Personality traits, such as perfectionism and rigidity, may be predisposing factors. High personal expectations and low self-esteem are also considered risk factors.

PANDAS subgroup
PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcus) is a term for a subgroup of children who have a sudden onset of OCD symptoms after a streptococcal infection.

The mechanism is unknown and the effectiveness of prophylactic antibiotics is inconsistent.1

The ICD-10 diagnostic criteria for OCD in children are similar to those for adults (see box 1).

However, children are less likely to have insight into the obsessions and compulsions, leading to a delay in seeking treatment.

Section 2: Making the diagnosis

Patients who have OCD often go undetected before an accurate diagnosis is made. The nature of these obsessions may often lead to reluctance in discussing them, resulting in a delay in seeking help.

It is important to identify signs early and to undertake steps towards considering appropriate treatment. Most cases should be referred to secondary care.

When making the diagnosis, consider the following:

  • Detailed history of obsessive and compulsive behaviour
  • Functional impairment, such as time spent doing rituals
  • Brief developmental history
  • Physical examination (dry skin from excessive washing)
  • Other psychiatric illnesses, for example, autism
  • Mental state examination
  • Assessment of risk of self-harm or suicide
  • Family history of psychiatric illness or similar traits
  • Medication history

Behavioural indicators of OCD include attempts to conceal symptoms owing to embarrassment. Children are likely to lack insight into the irrationality of their obsessions.

It is important to differentiate true compulsions from normal ritualistic and routine behaviours. The compulsion needs to be distressing and/or impairing.

Avoidance is an integral part of the symptoms, where a patient takes care not to touch toilet seats, door handles or other items used by others.2

Parents of children with OCD may accommodate their symptoms and provide constant reassurances. Children often react aggressively when a family member does not adhere to their compulsions.2

OCD can often be associated with other psychiatric disorders, such as depression, anxiety disorders, eating disorders, body dysmorphic disorder, hoarding disorder and trichotillomania.

The patient's beliefs and fears are best elicited by face-to-face assessment, although parents may be better placed to report ritualistic behaviours.

The short OCD screener (see box 2) provides a framework for screening and onward referral.

Box 2
  • Do you wash or clean a lot?
  • Do you check things a lot?
  • Are there any thoughts that bother you that you would like to get rid of, but cannot?
  • Do your daily activities take a long time to finish?
  • Are you concerned about putting things in a special order or very upset by mess?
  • Do these problems cause you to feel troubled?

Source: NICE CG31

Differential diagnoses
Common differential diagnoses are:

  • Autism spectrum disorders (ASD): stereotyped behaviours in OCD are not pleasurable and associated with relief in anxiety. OCD can also be present in children who have ASD
  • Complex tic disorders
  • Psychosis: the presence of other characteristic symptoms in psychosis, such as hallucinations and delusions1

Section 3: Managing the condition

For a young person with symptoms of OCD with mild functional impairment, guided self-help should initially be offered through primary care or early intervention services. If this is refused or ineffectual, they should be referred to secondary care.

If the young person presents with moderate to severe functional impairment, a secondary care referral should be made. Patients with a previous history of OCD with a relapse in their symptoms or with associated comorbidities should also be referred to secondary care.

A referral letter explaining why a particular route has been chosen should accompany referrals. The letter should include current symptoms, and degree of impairment and interference, as well as other information relevant to risk and comorbidities.

Two treatments have an established evidence base in paediatric OCD, namely CBT, incorporating exposure and response prevention (E/RP), and SSRIs.

Central to any psychological therapy is a thorough case formulation that involves a collaborative understanding of the patient's difficulties.3 CBT includes initial psychoeducation that aids engagement and is necessary for the development of a therapeutic relationship, crucial if change is to be made possible.4

Typically, CBT is a short-term treatment consisting of 12-20 weekly sessions. The main therapeutic strategy is E/RP, which involves the patient confronting their fears in a graded manner, with help from the therapist and family members.

Involving the patient's family is crucial in helping family members to stop accommodating the child's compulsions.5,6

RCTs have shown that CBT can be efficacious in paediatric OCD, associated with a 45-60% reduction in symptoms.7

SSRIs can be prescribed as an adjunct to CBT in cases where the patient has moderate to severe functional impairment, or when an initial 12 sessions of CBT have not been effective.8 RCTs have indicated a 29-44% reduction in symptoms over a range of SSRIs.2

In the UK, currently only sertraline and fluvoxamine are licensed for use in children with OCD, with sertraline as the first choice owing to its favourable side-effect profile. A specialist should initiate these medications.1

New developments
In recent years, there has been research into using novel approaches to delivering CBT, for example, by telephone and using the internet. Further validation on these methods is awaited.

Pharmacologically, there has also been an increase in research interest in the use of d-cycloserine to augment CBT. This therapy is mainly delivered in the community and inpatient treatment is rarely required.

Section 4: Prognosis

OCD in young people, with factors such as secretiveness and a lack of desire to change, can negatively affect the likelihood of recognition and engagement in treatment.9

Higher levels of functional impairment, family conflict, parental blame and poor insight have been associated with poorer outcomes.

The presence of comorbid psychiatric disorders, specifically oppositional disorders and/or ADHD, makes compliance with OCD treatment more difficult.

Positive outcomes have been linked to higher treatment expectations and therapeutic alliance.10 A calm, supportive family environment, in which parents and/or caregivers can support the child's coping strategies, can improve outcomes.

CBT should involve relapse prevention strategies and follow-up review appointments can be helpful.

Section 5: Case study

HK is a 10-year-old girl with a two-year history of repetitive activities, involving getting dressed and rewriting words.

Her mother told the GP that HK had to pull every item of clothing on and off 25 times when dressing for school in the morning, making her late for school every day.

Her schoolwork also suffered because she felt the need to rewrite each word up to 25 times. If interrupted, she felt compelled to start counting again from the beginning.

HK's experiences were affecting her family, who were supportive but felt overwhelmed and unconfident about how to help her.

HK had attempted to conceal her difficulties, because she felt revealing them would mark her out as different, strange or mad. She had been unable to hide her distress before an important test at school, which increased her obsessional thoughts and compulsive behaviours.

Her GP elicited information from HK and her mother in a supportive and sensitive manner, with additional focus on other comorbidities. A referral to secondary care was made for a routine assessment.

Following the initial assessment in secondary care, it was concluded that HK's symptoms were consistent with OCD. A detailed assessment letter, with a formulation and management plan, was sent to the GP.


HK was offered 12 sessions of CBT, to include E/RP and family sessions with a clinical psychologist.

In the early stages of treatment, HK and her family reported a decrease in her symptoms of repetitive actions. These improvements had a positive impact on HK's mood.

Her treatment also included using behavioural experiments (E/RP). HK and her family remained engaged in treatment, so her symptoms continued to improve.

Medications were not considered in this case because of the positive effect of CBT.

Following completion of treatment, HK was discharged back to her GP with a summary of her management and relapse prevention plan.

Section 6 Evidence base

Clinical trials

  • Barrett, P, Farrell L, March J. Cognitive-behavioral family treatment of childhood OCD: a controlled trial. J Am Acad Child Adolesc Psychiatry 2004; 43: 46-62.

Here, CBT was associated with better responses and longer-term benefits, compared with psychoeducation plus relaxation training.

  • Watson H, Rees C. Meta-analysis of randomized, controlled treatment trials for pediatric obsessive-compulsive disorder. J Child Psychol Psychiatry 2008; 49(5): 489-98.

This meta-analysis indicated that CBT is shown to reduce symptoms by 40-65% in a paediatric population.

  • Torp NC, Dahl K, Skarphedinsson G et al. Effectiveness of cognitive behavior treatment for pediatric obsessive-compulsive disorder: Acute outcomes from the Nordic long-term OCD treatment study (NordLOTS). Behav Res Therapy 2015; 64: 15-23.

This study found that manualised CBT could be applied effectively in community mental health clinics.

  • NICE. Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. CG31. London, NICE, November 2005.

Key text

  • Rutter M, Bishop D, Pine D et al (eds). Rutter’s Child and Adolescent Psychiatry (fifth edition). Oxford, Wiley-Blackwell, 2008.


These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Review the notes of a few patients diagnosed with OCD and reflect on factors that could have led to an earlier diagnosis.
  • Invite a CBT therapist to discuss simple measures that could be implemented to manage OCD in the early stages, as a learning tool for the clinical team.
  • Review the criteria for referral to secondary care for children and adolescents with OCD.

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1. Veale D, Roberts A. Obsessive-compulsive disorder. BMJ 2014; 348: g2183.
2. Krebs G, Heyman I. Obsessive-compulsive disorder in children and adolescents. Arch Dis Child 2015; 100(5): 495-9.
3. Johnstone L, Dallos R. Formulation in Psychology and Psychotherapy: Making Sense of People’s Problems. Hove, Routledge, 2013.
4. Lambert MJ, Barley DE. Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training 2001; 38: 357-61.
5. Salkovskis PM. Obsessional-compulsive problems: a cognitive-behavioural analysis. Behav Res Therapy 1985; 23: 571-83.
6. Wells A, Matthews G. Attention and emotion. A clinical perspective. Hove, Erlbaum, 1994.
7. Torp NC, Dahl K, Skarphedinsson G et al. Effectiveness of cognitive behavior treatment for pediatric obsessive-compulsive disorder: Acute outcomes from the Nordic long-term OCD treatment study
(NordLOTS). Behav Res Therapy 2015; 64: 15-23.
8. NICE. Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. CG31. London, NICE, November 2005.
9. De Haan E. Effective treatment of OCD? J Am Acad Child Adolesc Psychiatry 2006; 45: 383-501.
10. Fonagy, P, Target M, Cottrell D et al. What Works for Whom? A Critical Review of Treatments for Children and Adolescents. New York, The Guildford Press, 2002.

  • Contributed by Dr Eloise Donaghay-Spire, clinical psychologist, and Dr Vibhav Shetty, consultant child & adolescent psychiatrist, South Kent CAMHS, Sussex Partnership NHS Foundation Trust.

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