Editorials

Children with obsessive compulsive disorder

Obsessive compulsive disorder in young people is common and under-recognised. Estimated prevalence rates in children and adolescents are about 1%.¹ The distress to young people caused by the characteristic intrusive, unwanted, and often unpleasant thoughts or fears is often hidden, as children identify these symptoms as peculiar or embarrassing and keep them secret, sometimes for years. Likewise, compulsive behaviours such as washing or checking are usually perceived as unnecessary and often ridiculous, and children may go to great lengths to conceal them.

The psychopathology is strikingly similar to that seen in the adult disorder, and many adults diagnosed with obsessive compulsive disorder report that their symptoms first began in childhood.² Parents, teachers, and primary care practitioners, as well as paediatricians and child psychiatrists, may well be familiar with the symptoms, and if children are asked directly they can often give lucid accounts of their problems, which are easily distinguished from ordinary childhood superstitions or rigidity. In addition to causing acute distress and disruption to education and friendships, obsessive compulsive disorder in children can be highly disabling, associated with chronic psychiatric morbidity, as well as severe long term social impairment.³ Evidence exists that early detection and assertive treatment are important for minimising the impairment experienced.⁴

Cases of obsessive compulsive disorder have been noted in association with brain injury and postencephalitic states, as well as with basal ganglia disorders such as tics and Tourette syndrome.⁵ Imaging studies have revealed both structural and functional basal ganglia abnormalities, and, significantly, obsessive compulsive disorder is one of the first psychiatric disorders where both psychotherapy and drug treatment have been shown to reverse the functional metabolic changes.⁶ Although the nature of the symptoms, particularly those linked to cleaning, checking, or other apparently "perfectionist" activities, have made them favourite candidates for psychodynamic interpretations, the mounting evidence for a neuropsychiatric basis has helped guide effective interventions.

The first clinical trials demonstrating responsiveness to serotonin reuptake inhibitors were reported over 10 years ago, and many studies have now shown the effectiveness of clomipramine in children with the condition. More recently, the specific serotonin reuptake inhibitors (SSRIs) have also been shown to be effective.⁷ As in adults, the other effective treatment for children is behaviour therapy, based on exposure and response prevention strategies. Protocols have been developed specifically for use in children⁸ and deserve wider use and evaluation.

Obsessive compulsive disorder in children has traditionally been classified as an anxiety disorder, and anxiety certainly is a core component. But for children to obtain optimum treatment both psychosocial and neurobiological aspects must be appreciated.

Children with obsessive compulsive disorder will probably not all be equally responsive to treatment. One of the most important research drives is the need to understand and define the heterogeneity within the disorder, which in turn will doubtlessly provide pointers to the most appropriate treatments for different subtypes. For example, a group of children has been identified who aquire acute onset obsessive compulsive disorder related to an autoimmune response to streptococcal infection.⁹ It remains to be seen whether such subgroups have equivalent responsiveness to medication or behavioural intervention.

To target treatment appropriately children with obsessive compulsive disorder need careful evaluation to rule out normal developmental variations, depression, and autistic disorders. A thorough assessment of symptom severity and consequent impairment is a good guide to the need for treatment; diagnostic instruments designed for use in children are widely used in specialist centres.¹⁰ If obsessive compulsive disorder is diagnosed it is clear that most children will benefit from a trial of medication and many from medium to long term drug treatment. Likewise, most children warrant assessment for behavioural treatment, and many will respond favourably to a structured course of behavioural treatment based on exposure and response prevention. Children and adolescents with this disabling condition should not fail to get well validated and specific treatments, either because the disorder remains undetected or because of lack of expertise in delivering these treatments.

Isobel Heyman, Lecturer ^a

^a Department of Child and Adolescent Psychiatry, Institute of Psychiatry, London SE5 8AF i.heyman@iop.bpmf.ac.uk

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9. Swedo SE, Leonard HL, Garvey MA, Mittleman B, Allen AJ, Perlmutter SJ, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS): a clinical description of the first fifty cases. Am J Psychiatry (in press).
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