Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 3: Children and Mental Health
Overview of Mental Disorders in Children
Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD), which is classified in DSM-IV as an anxiety
disorder, is characterized by recurrent, time-consuming obsessive or compulsive
behaviors that cause distress and/or impairment. The obsessions may be
repetitive intrusive images, thoughts, or impulses. Often the compulsive
behaviors, such as hand-washing or cleaning rituals, are an attempt to displace
the obsessive thoughts (DSM-IV). Estimates of prevalence range from 0.2 to 0.8
percent in children, and up to 2% of adolescents (Flament et al., 1998).
There is a strong familial component to OCD, and there is evidence from twin
studies of both genetic susceptibility and environmental influences. If one twin
has OCD, the other twin is more likely to have OCD if the children are identical
twins rather than fraternal twin pairs. OCD is increased among first-degree
relatives of children with OCD, particularly among fathers (Lenane et al.,
1990). It does not appear that the child is simply imitating the relative’s
behavior, because children who develop OCD tend to have symptoms different from
those of relatives with the disease (Leonard et al., 1997). Many adults with
either childhood- or adolescent-onset of OCD show evidence of abnormalities in a
neural network known as the orbitofrontalstriatal area (Rauch & Savage, 1997;
Grachev et al., 1998).
Recent research suggests that some children with OCD develop the condition after
experiencing one type of streptococcal infection (Swedo et al., 1995). This
condition is referred to by the acronym PANDAS, which stands for Pediatric
Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections.
Its hallmark is a sudden and abrupt exacerbation of OCD symptoms after a strep
infection. This form of OCD occurs when the immune system generates antibodies
to the streptococcal bacteria, and the antibodies cross-react with the basal
ganglia13 of a susceptible child, provoking OCD (Garvey et al., 1998). In other
words, the cause of this form of OCD appears to be antibodies directed against
the infection mistakenly attacking a region of the brain and setting off an
inflammatory reaction.
The selective serotonin reuptake inhibitors appear effective in ameliorating the
symptoms of OCD in children, although more clinical trials have been done with
adults than with children. Several randomized, controlled trials revealed SSRIs
to be effective in treating children and adolescents with OCD (Flament et al.,
1985; DeVeaugh-Geiss et al., 1992; Riddle et al., 1992, 1998). The appropriate
duration of treatment is still being studied. Side effects are not
inconsequential: dry mouth, somnolence, dizziness, fatigue, tremors, and
constipation occur at fairly high rates. Cognitive- behavioral treatments also
have been used to treat OCD (March et al., 1997), but the evidence is not yet
conclusive.
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